Chronicle Investigation Tracks Abuses, Understaffing at CA For-Profit Psychiatric Hospitals
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From KQED in San Francisco, I'm Mina Kim. Coming up on Forum, California is increasingly relying on for-profit psychiatric hospitals to care for people experiencing severe mental health crises. A new San Francisco Chronicle investigation finds these private facilities are understaffed to maximize profits and are, quote, exposing patients to erratic care, violence, and deadly neglect.

The companies dispute these findings and are poised to play a bigger role under the state's sweeping mental health care reforms. We learned more from the reporters behind the investigative series Failed to Death. Join us.

Welcome to Forum. I'm Mina Kim. A new investigation by the San Francisco Chronicle finds that in the last six years, hundreds of patients at California's for-profit psychiatric hospitals have reported physical and sexual abuse. Seventeen have died. These are far more incidents than at state-run or non-profit facilities, and yet the state is increasingly relying on these private companies to provide care to the thousands who experience serious mental health crises every year.

This hour, we learn more about why this is happening at private facilities and what can be done about it. And a warning to listeners, this conversation is likely to include discussions of suicide and sexual assault. Joining me this hour, Joaquin Palomino, investigative reporter at the San Francisco Chronicle. Hi, Joaquin. Thanks for being with us. Hi, Mina. Thanks for having me. Cynthia Dizekas is also with us, investigative reporter at the Chronicle as well, both part of the Failed to Death investigative series.

And Cynthia, so when you say the role of for-profit psychiatric hospitals has grown in recent years, give us a sense of what you mean by how much. Absolutely. So in a nutshell, our investigation really found that understaffing

And the resulting harm from that has been allowed to happen in the state's psychiatric hospitals run by for-profit companies. And this is a bigger deal now as the state is embarking on an unprecedented expansion of its behavioral health care system under Governor Gavin Newsom that is poised to direct even more people into these institutions.

And what we found was that for-profit hospitals in particular have been able to add hundreds of beds across the state, even as they have stripped their workforces bare, resulting in violence and deadly neglect for patients. Did I see right that since 2019, there's been roughly a 33% increase in the number of beds that are in for-profit entities? That's right. And that has come in the form of

beds that have been added to existing facilities, as well as new facilities being built across the state. And when you look at comparative institutions like nonprofit psychiatric hospitals and psychiatric units in general hospitals, those bed counts have remained relatively flat.

over the same period of time. Why have they remained relatively flat? So we looked into that, and a lot of it has to do with the profit margin that these companies are able to meet. And in for-profit hospitals, a lot of that comes down to staffing. And the lower you bring your staffing costs, the more profits you have and the more ability to expand. So there's all this expansion going on, Joaquin, at the same time that your investigation found

So many complaints, hundreds of complaints at these for-profit facilities over a six-year period. Help us wrap our minds around the number and the types of complaints that the state health department has received. Yeah. So for our investigation, we reviewed, they're called deficiency reports that the California Department of Public Health issues to any hospital when they respond to a complaint.

or an incident that's reported by the facility itself. And we looked at a six-year period and we found hundreds of these serious safety lapses that were cited by CDPH, or the California Department of Public Health, at for-profit psychiatric hospitals. These included physical and sexual assaults, improper restraints, deaths that were linked to some sort of deficient care,

And other abuses. And we looked at these reports, both for the for-profit facilities and for one year we looked at a comparative year for nonprofit psychiatric hospitals and psychiatric units in medical hospitals.

And we found that the number of these serious safety violations were much higher relative to admissions at the for-profit facilities. And we also, in looking at these reports, there's a lot of evidence that

hospitals are not reporting, particularly the for-profit psychiatric hospitals are not reporting a lot of very serious assaults or other violence or abuse within the facilities. CDPH will sometimes come in and cite them for that. And so these numbers are still really safe to say

probably a vast undercount of the actual harm occurring. So they're a vast undercount. And yet at the same time, I was so struck by the statistic that there were three times as many serious safety violations at for-profits and at general hospitals or nonprofits in a one-year period. So tell us about some of the people that you learned were affected by these violations, one of them being Tyler Thatcher Cox in San Diego, Cynthia? Yeah.

That's right. So part of our reporting over the last year has, of course, been trying to connect with as many people as possible who have touched this behavioral health care system. And that means people who've worked in the facilities, but most importantly, people who have sought

care from them and their loved ones. And so we were able to connect with the family of Tyler Thatcher Cox, who was a 22-year-old man living in San Diego. And he had struggled for a really long time with depression, and that worsened after his mother died.

of cancer. And he was really in crisis. And so like many people in the state, he and his family found themselves at a local emergency department after he had attempted suicide in June of 2022. And

You know, this is a part of the process that we learned about in reporting this and that I think a lot of people don't know that if you're placed on an involuntary psychiatric hold, it's called in California a 5150 hold after the death.

the part of state law that allows authorities to detain people if they are a danger to themselves or others or are unable to take care of their basic needs due to mental illness. And once you are placed on that hold, you don't really have a choice of where you are sent. It comes down to what facility has a bed that is willing to accept you and your insurance.

And in Tyler's case, he ended up going to a facility called Aurora San Diego, which is owned by Signature Healthcare Services, which is the largest operator of for-profit psychiatric hospitals in California. What happened when he got there? So we spoke to his family extensively about that, particularly one of his aunts.

aunts, Debbie Thatcher, and she had actually seen online reviews of really negative online reviews of the hospital and had asked the doctors at the emergency department to not send him there. But as we said, they don't really have control over that. And so he got there. And from what she told us, he immediately called her and he was really scared. And

I think it can be a very frightening experience to be detached from your support systems and the people you love. And he really didn't know what was going to happen to him.

The panic grows, it sounds like, and he starts to create a noose out of sheets and is put under constant monitoring, right? Exactly. So we were able to piece together what had happened to him in the facility from the conversations that his family had with him, but also his medical record, which they shared. And it shows that a few days after arriving, his...

The crisis he was in was not resolving, and staff members found him twisting his sheets into a noose. And at that point, the doctor at the facility placed him on line-of-sight observation, which is an increased level of observation where a staff member is supposed to keep him. It's exactly what it is.

says in line of sight at all times. And so he goes on that and they even move him into this, what they call their quiet room. And it is directly next to a nurse's station. It has a bedroom and a separate bathroom. And they put patients there who are particularly ill, who

to watch them, to make sure that nothing happens to them. And so he goes into that room and instead of being watched, no one even knows he's there. And he is left alone for two hours, in which time he is able to complete suicide. Mm-hmm.

How long was it before they discovered that he had done that? So, and again, this comes from video footage that we were able to see from the hospital, but he...

In this footage, you can see he is in great distress. Around 3.30 p.m. on July 4th of 2022, he is walking back and forth in his room, twisting his bedsheets. At one point, he sits down and he is, you know, hitting his head against the wall and really seems in a lot of turmoil. And

He is there until around a little bit after 6 p.m. when they discover that he is in the bathroom and they can't open the bath door. And this was a couple hours afterward. Exactly. Yeah. What did Tyler's family say they believe is the reason that Tyler died? So they said, as you...

They would point out in the video that the reason he died is that no one did their job in this case. Their main job was to watch him. He had been identified as being at really grave risk of suicide, and then no one did. And you've called what happened to Tyler and what happened at Aurora emblematic of issues like

Broader issues at for-profit hospitals. And is that specifically staffing? That's specifically staffing. And it was interesting because the family did file a lawsuit. And as part of that lawsuit, they took depositions from some of the workers who were on shift that afternoon. And one of the workers said in this sworn deposition that he, first of all, didn't know that

Tyler was on line of sight and that his the rest of his colleagues had kind of left him on the unit to watch all the patients by himself. And so that was really an indication to us as well that staffing was something that was underlying the events that happened on that day.

We're talking with Cynthia Tezikis, investigative reporter at the San Francisco Chronicle, and Joaquin Palomino, also investigative reporter at the San Francisco Chronicle. Both of them have reported the Failed to Death series that looks at for-profit psychiatric hospitals, how they're the fastest-growing destination for thousands of Californians experiencing mental health emergencies, and yet they have lost.

A large and particularly undercounted record of incidents or complaints at these facilities. Listeners, join the conversation. What questions do you have about our reporters' findings? Have you worked at or been a patient in a psychiatric hospital? Has a loved one? What was your experience? You can email forum at kqed.org. Find us on our social channels on Blue Sky, Facebook, Instagram, or Threads. And you can call us at 866-733-6786.

866-733-6786. More after the break. I'm Mina Kim.

Hi, I'm Morgan Sung, host of Close All Tabs from KQED, where every week we reveal how the online world collides with everyday life. You don't know what's true or not because you don't know if AI was involved in it. So my first reaction was, ha ha, this is so funny. And my next reaction was, wait a minute, I'm a journalist. Is this real? And I think we will see a Twitch streamer president, maybe within our lifetimes. You can find Close All Tabs wherever you listen to podcasts.

Each morning, it's a new opportunity, a chance to start fresh. Up First from NPR makes each morning an opportunity to learn and to understand. Choose to join the world every morning with Up First, a podcast that hands you everything going on across the globe and down the street, all in 15 minutes or less. Start your day informed and anew with Up First by subscribing wherever you get your podcasts.

Welcome back to Forum. I'm Mina Kim. We're talking this hour about a new chronicle investigation failed to death about the conditions at for-profit psychiatric hospitals, the fastest growing destination for thousands of Californians experiencing mental health emergencies every year. Listeners, have you worked or been a patient in a psychiatric hospital here in California, a loved one? What has been your experience? What do you think needs to be done if you feel there are changes that are needed at psychiatric hospitals to care for the well-being of patients?

With us is Cynthia Dizekas, investigative reporter at the San Francisco Chronicle, along with her colleague in reporting, Joaquin Palomino, another investigative reporter at the San Francisco Chronicle. Listeners, you can join the conversation by calling 866-733-6786, posting questions or comments about their investigation on our social channels or by emailing forum at kqed.org.

Walking just before the break, we were talking about Tyler's story and about the concerns about staffing levels and that staffing problems being an issue festering in for-profit psychiatric hospitals. What were the staffing levels at Aurora when Tyler Thatcher Cox was admitted? So we looked at all hospitals have to report a lot of financial data and staffing workforce information to the state. And so we looked at that data statewide and also at Aurora San Diego during the year that Tyler was admitted there.

And we found that the year Tyler was admitted, Aurora San Diego had much lower staffing levels than many other of the psychiatric hospitals in San Diego County. The hospital also spent much less per patient than other psychiatric hospitals, either nonprofits or those that were housed within medical hospitals. And this is true.

This trend plays out across the state. We found that overall for-profit psychiatric hospitals have far fewer staff members than their counterparts in nonprofits or in medical hospitals. And that the sort of frontline workers that they do have tend to be

paid less. They rely less on registered nurses, for example, more on sort of unlicensed workers who don't always have to have any background in behavioral health care. And that seems to be at sort of the root of a lot of the problems that we identified. We talked to a lot of staff members who sort of described just feeling very overwhelmed by their workloads, having to watch

A single nurse watching 19 patients at a time, which is far higher than what is mandated for medical hospital psychiatric units. Some of the state deficiency reports we reviewed as well describe these just really overstretched workers who are sometimes put in these literally impossible situations where they are assigned to watch

too many patients than what they physically can, because in some cases, they might have to be within arm's length of two different patients in two different rooms. And it's something that they cannot do. And then as a result, there are often these really serious sort of safety issues that transpire. We actually have on the line now a former worker at a for-profit psychiatric hospital, Alexandra Del Sima. Alexandra, thanks so much for being with us.

Hi, of course. So you worked as a mental health technician from 27 to 2019 at Heritage Oak Hospital in Sacramento. It sounds like you had a pretty tough experience there that you got really hurt on the job at one point. What happened? Yes. Kind of touching back on what you guys said about the quiet room. I don't really think I talked to Joaquin and Cynthia much about that because it really just gets forgotten about sometimes.

Most of my shifts, I worked knock shift, which was 11 p.m. to 7 a.m., and then eventually I moved to swing shift from 10 p.m. to 2 a.m. But I was normally 1 to 26 on a unit, and we would have multiple 1 to 1s, or what were called Q5s, which means they needed to be checked on and visualized every five minutes. And given the fact that I would have upwards of 20 patients every shift, it's almost impossible to do that because...

You're running group and you're getting snacks and you're getting juice and you're taking people to get their meds and doing your regular checks, which were always Q15s, which was like the base.

For anybody that came in, they had to be checked on and visualized every 15 minutes. And then when you add, you know, five, few fives to that, it's you're running around all over the place and you're one person expected to run an entire unit. Because our nurses at the time were in the nursing station, which was behind a locked door or like a big piece of plexiglass. So there was only one of us on the unit most of the time. And there was an incident that made you look into the staffing ratios. What was that incident?

Yeah, so I was working at one of our more acute units, meaning that these patients were more likely to act aggressively or kind of get agitated easily. And I was talking to someone that was what was called dual diagnosed, and he was withdrawing from methamphetamine as well as having a psychiatric crisis. And being the one staff on the unit, I was just having a conversation with him. And out of nowhere, he punched me.

straight in my forehead. And I was out of work for eight weeks. I had a pretty severe concussion and wasn't allowed to drive or take care of my kids or anything. And once that happened to me, I was like, there's no way that this can be safe because by the time that I was on the ground, I had other patients helping me before other staff members or colleagues even knew that I was hurt. So I kind of started looking into things and got in contact with the CDPH and

and learned the actual ratios that were to be expected within psychiatric facilities. And it was not one to 26. At the time, I believe it was supposed to be one license, which was not me. I was just a tech to six patients. And that was not even close to what was being ran. And then I also talked to Cynthia and Joaquin about how we would get canceled. Like they would put us on a schedule and

and, you know, make it look like we were staffed properly. But then an hour before our shift, we called what was called the nurse canceled line. And they would say, oh, well, you know, we're not needed tonight. You know, since this is too low, we don't need you guys to come in and our shift would be canceled. And then once they actually started getting investigated, when I, I guess, submitted my complaint, I took pictures of all of the original schedules that I was on. They actually falsified the documents to make it look like they were staffing properly.

Wow, Alexander, I'm so sorry for all the things that happened to you around this incident, as well as the incident itself. When you did learn from Cynthia and Joaquin that staffing levels at for-profit hospitals was, at least through their investigation, a widespread problem, were you surprised?

I was honestly kind of surprised that it was more widespread than just that hospital. I did know that it was a for profit hospital and worked with a lot of assessment and referral patient workers like the clinicians.

And I would hear them make comments like, oh, one empty bed, like we're losing so much money. You know, we need to fill this bed. And I continued my nursing career. I work as a nurse now with a license. And having heard that now, it's like we want hospital beds to be empty. We want people to be home and healthy. We don't want

people to be in our beds just to make money. So just to have that mentality, I couldn't really fathom that it was as widespread as it was. But I guess after talking to them and understanding that people only care to line their own pockets, even if that comes at other people's expense. Yeah.

Alexandra DelSima, who worked as a mental health technician from 2017 to 2019 at Heritage Oaks Hospital, a for-profit in Sacramento. Really appreciate you coming on to tell us your story. Thank you so much. So what...

have the hospital, the companies. First of all, Cynthia, who are the four for-profit companies that run in California? And what have they said about your findings? So the four main companies, there are 21 for-profit psychiatric hospitals in California. And they, almost all of them, are run by Signature Healthcare Services, Universal Health Services, Acadia Healthcare, and College Health Enterprises.

And the majority of them are really run by Signature and Universal, with Acadia really expanding its footprint in the state. And so we reached out to all of these companies with our findings. And all of them pretty much said the same thing. They said that...

They are serving a critical role in the community. People in crisis need to have treatment beds to go to and that this can also be a challenging and unpredictable patient population. And all of them also refuted our findings that they were understaffed in comparison to the other facilities that provide these services and said that they, you know, hire enough staff and they hire based on the needs of patients.

Well, listener Anne writes, I work in acute care as a nurse in San Francisco serving a lot of patients with mental health issues. It all boils down to staffing. This population is challenging and burnout is real. Sometimes we don't get breaks. So it's interesting, Joaquin, Alexandra said that when she checked, it looked like the staffing level was supposed to be 1 to 6. She had 1 to 26. California does mandate nurse-to-patient ratios at general hospitals, as I understand it.

Do they also at psychiatric hospitals? So this was something that sort of we uncovered in our reporting. 20 years ago, California became sort of a groundbreaking, passed a groundbreaking law that established these minimum nurse to patient ratios in all sorts of units in medical hospitals. And so within psychiatric units of medical hospitals, that is one nurse or licensed psychiatric technician to six patients, right?

And so that is the minimum level that the psychiatric units in medical hospitals like San Francisco General, let's say, must meet.

These facilities that we're looking at are licensed as freestanding acute psychiatric hospitals. And so they're licensed separately. And under this staffing ratios law, they were never – those ratios were never created for freestanding psychiatric hospitals. When we look back at sort of the regulatory records from the time –

The state had promised to create these ratios. Under state law, it still says that these ratios will be created or shall be created. At psychiatric hospitals. At psychiatric hospitals, but they still have not been. They still have not been. Because Stephen on Discord writes, Steve on Discord writes, change the law. I think it's the only way to fix this. Private hospitals with inadequate staffing should have patients transferred out of those facilities. Harms to patients should be grounds for

for losing their license. Is there any plan on the horizon to go ahead and pass those staffing ratios? Can they do that administratively? Does it have to be done legislatively again? Yeah, so the important distinction here is the law doesn't need to be changed. There is a law on the books saying that the state health department is required to set these ratios. And as Joaquin was saying, what we found is

they just never have. And so at least the experts we talked to said that there is no additional legislation that would be needed for the governor to direct the health department to begin what they call the rulemaking process around that. So the agency has to go through a process where they hear from stakeholders, but that process would be to set similar ratios as are in psychiatric units in general hospitals.

Let me go to call her, Catherine in Alameda. Hi, Catherine, you're on. Hi, how are you? I'm well. How are you? Thanks for calling in. What's on your mind? Well, I just wanted to share, I have bipolar and I'm 55. I've been hospitalized a few different times. A couple of times, I hope I'm able to say the hospital's name, but the worst experience that I had was, and I think this is not a private hospital, but I was at John George Hospital.

And I've been around a lot of people with dual-diagnose and mental health issues. And this is, like, the worst place to go. But my experience was when I first got in, they put you in this room. And, like, you have to have – you're on a mat in this huge room. They kind of corral you into this huge room. And you have to spend the night on this mat. And I just remember it being really scary. And I remember, like –

being harassed kind of by like followed around by a male, a kind of by like, not just, he was kind of like, you know, not sexually harassing me, but I was scared for that reason in a sense. And, um, I would never go back there. I mean, I will take my meds every day and I will do whatever I can to not be hospitalized, especially there. Um, I haven't been to Eric, but I've been to Fremont hospital, but, um,

That place was a nightmare. And I've been around people that have worked there, and I don't know. I just, no way. Never going back. Thank you so much for sharing your story. And of course, there are incidents across, it's a difficult time.

It's a difficult role as a psychiatric hospital given the different types of things that happen there. And so certainly there are probably issues, as Catherine is describing, across many different types of hospitals. One of the keys, though, being that in your case, for-profits seem to be outpacing these other hospitals when it comes to incidents and complaints. What has the governor's office said about your findings or the California Department of Public Health?

Yeah, so we reached out to both the governor's office and the California Department of Public Health with sort of the findings of

of our investigation. Uh, the department of public health said that they were going to, uh, sort of review some of these incidents that we had brought to their attention, um, as well as, uh, potential underreporting by hospitals of violent incidences, incidents that occurred within the facilities. Uh, they also signified that they're going to sort of look into this rulemaking file that Cynthia referenced, um, which was sort of the initial, uh, uh,

regulatory records or regulatory files related to setting the staffing ratios in medical hospitals and psychiatric hospitals, or I guess the absence of those ratios in psychiatric hospitals. And then the governor's office also said that they, you know, took our findings seriously, that they, you know, had concerns about the treatment that some of the patients were

received in these facilities and that they were also sort of paralleling CDPH going to sort of look into what could be done to address it.

Nick writes, about 20 years ago, I was a juvenile patient at an Aurora facility in Ventura, Vista Del Mar Hospital. In my experience, the psychiatric technicians were great. Most of them cared and honestly made the experience more bearable. However, the doctors were horrendous. They just wanted to spend the minimum amount of time with you and didn't seem interested in good treatment. I don't recall spending more than five minutes with one of the doctors. Joaquin, you also looked at

how much for-profit hospitals potentially saved by having a much larger staff-to-patient ratio, especially on providing direct care, right? What did you find?

So, yeah, all the hospitals have to report how much they're spending on direct patient care. And so this is mostly includes costs for salaries and benefits for like the frontline workers, like nurses, mental health workers, as well as any other expense that is directly going towards patient care.

We found that for-profits are spending far less on patients than nonprofits or medical hospitals, and this has helped contribute to these really massive earnings at some of these companies across all of the companies over a five-year, six-year period from 2019 onward.

We found that the 21 for-profit psychiatric hospitals reported, I want to say it was hundreds of millions, I think about $460 million in profits alone. And this, again, is within sort of a sector where it can be really hard to make money. A lot of medical hospitals are not making money in their psychiatric units, but these companies have found a way to really make money.

Turn a lot of profit here. And just really quick, Cynthia. So if the law doesn't require psychiatric hospitals yet to have the one to six, are you, though, finding that nonprofit hospitals or medical or general hospitals do maintain something closer to a one to six?

Yeah, so this was really interesting to us in this comparison. As we've been talking about, the psychiatric units in general hospitals have this one to six ratio. Freestanding psychiatric hospitals don't. They are governed by these looser regulations that allow them to staff based on the needs of patients. And

Yet, nonprofit-run psychiatric hospitals, we saw in the data that Joaquin mentioned, still choose to staff at levels that are much more similar to the general hospital psychiatric units.

We're talking with Cynthia Dizekas and Joaquin Palomino, investigative reporters for the San Francisco Chronicle on the series Failed to Death, which found that hundreds of patients in California's for-profit psychiatric hospitals have reported physical and sexual abuse far more than at nonprofit and general hospitals over a six-year period. We'll have more with them and with you listeners after the break. Stay with us. You're listening to Forum. I'm Nina Kim.

This is Forum. I'm Mina Kim. A Chronicle investigation finds there are more incidents, more complaints, more violations at for-profit psychiatric hospitals than at non-profit ones, largely because they're understaffed to maximize profits. Private companies dispute these findings, and under Newsom's ambitious plan to get more people into mental health treatment, the role for for-profit hospitals is expected to grow, and the money these hospitals get from the state is expected to grow as well. And I want to ask you about that, Cynthia. So,

Now, these private companies, the four that you mentioned, Signature, Acadia, and so on, they're applying for Prop 1 money, right? Because that was a lot of money that voters approved for California to expand mental health care services. So what are they applying for? Do we know if they're getting these contracts or these grants?

So that's a great question. And it's something we're following. We are the state is currently in the first round of funding for Prop 1. And they've taken basically applications for from us.

institutions and facilities both locked and unlocked, residential, acute, all over the state. And they are evaluating those requests right now. And they're going to make their announcements in May of who has been awarded funding. And within that first round, there are some for-profit companies, Acadia and College, that have applied for about $250 million of these funds. And

And we will find out in May what happens with that. We've asked the state, are there any guardrails you're putting on this when it comes to what the for-profit hospitals are doing or the profit margins they're going to make off of that? And we are waiting for those answers, and we'll see what happens in May.

Acadia was the subject of federal government investigations and a New York Times investigation, right, last fall. I was wondering why they were familiar to me. And then that was why. What was Acadia accused of again?

So in that series, Acadia was accused of bringing in and keeping people on involuntary holds who did not meet that bar that we discussed, which is acute danger to yourself or others or unable to take care of your basic needs due to a mental illness and in order to make money. So that was the subject of that article. So bringing people and putting and keeping them longer than they should have been or even if they should have been on there at all.

Exactly. And they ended up settling a $20 million settlement with the Justice Department around those accusations, though Acadia has denied those allegations. And Joaquin, I think you were saying that, I'm not sure if it's Acadia, but maybe it's Acadia and Signature that have also grown very quickly and in the adolescent mental health care market? Yeah, so Acadia.

Universal and Signature are like the main players in California. Acadia is expanding as well here. They have three hospitals now and are applying for, as Vincent mentioned, some of that Prop 1 money. Within the adolescent space, the for-profit hospitals are operating the majority of the beds that are in hospitals designated to treat people on involuntary hold. So

Most of the places for children and teenagers who are experiencing some sort of psychiatric crisis and need to be placed on an involuntary hold, most of those beds are in hospitals run by for-profit companies, which includes...

Signature Universal, Acadia, and College Health Enterprises. And I should note the first piece in your series was about a 15-year-old who was held in an involuntary hold at a for-profit institution named Yasmin Pellegrini Hospital.

This is Nirmali writes, I worked as a nurse in Santa Rosa where patients were being held in a locked facility due to danger to themselves or others. I am still getting checks from class action lawsuits filed against the facility for their practices towards the staff. This was my first job as a nurse, so I had no idea these practices weren't normal. If the staffers aren't experienced enough to know how to protect their rights, how can they be trusted with the freedom of people who really need help?

Another listener, Patrick, writes,

Are we likely to see more oversight from the state as a result of your investigation? The fact that, you know, the growth of for-profit psychiatric hospitals has occurred nationwide and we're starting to see these issues that other entities are reporting on. So do you think that we are likely to see from the state, Cynthia, you know, an increase in...

in oversight and consequences, as Patrick is wondering, what does their track record tell you? Well, it's interesting Patrick mentioned nursing homes because the state, because of the abuses in the nursing home industry, the legislature has actually passed, they've mandated certain amounts of fines or mandatory suspensions on admissions if students

certain severe violations happen within those facilities. So one thing that might potentially be on the table is whether under CDPHs, the California Department of Public Health's oversight, if any of those mandatory fines or mandatory suspensions on admissions could come into play in the same way that the state has set those for nursing homes. And so what...

What are they doing when they find violations? Are they following through the way that you would expect? What tends to be, you know, the way that they operate when they fully investigate, uncover that a violation occurred? Yeah. So the Department of Public Health has tools to help.

deal with violations when they find them. They can issue financial penalties up to $125,000. Those are for really sort of serious safety violations and persistent safety violations. They can also issue lesser fines than that as well. They could suspend licenses, things of that nature. We found that even in the face of, you know, pretty serious safety violations that the Department of Public Health rarely sort of utilizes those tools.

Over this period of time, we looked at since 2019, we found that they've only issued fines of about $90,000 to three for-profit psychiatric hospitals, despite documenting, as we've mentioned, hundreds of these very serious safety violations. And so instead of issuing financial penalties, instead of pausing admissions, we found the state health department primarily relies on what they call plans of correction, where they essentially ask the hospitals to submit fines

a detailed plan explaining how they're going to try and rectify some of the violations that the state health department has cited. What did they do in the case of Tyler Thatcher Cox? So with Tyler, that investigation took two years for the Department of Public Health to complete. Actually, so Tyler...

died in July of 2022. The report came out just this past November. And in that, they did not issue any fines. As far as we know, they did find that, yes, the hospital was at fault. They found that the hospital was at fault. Yes, they issued a deficiency report sort of detailing how the hospital should have been monitoring Tyler but was not.

But as part of that process, they, as far as we could tell, decided not to issue any fines. And they just asked the hospital to submit a plan of correction. Steve on Discord writes, facilities with chronic problems should automatically lose eligibility for any further placements. Have you ever heard of CDPH doing that?

So interesting. We spent a lot of time looking for this. And at least since 2019, we could find no instance where a psychiatric hospital, a for-profit psychiatric hospital that had been repeatedly cited for serious violations had a pause put on their admission.

Interestingly, there was one case in, and another one of the callers mentioned this facility, Vista Del Mar, which is a signature facility in Ventura. It had a rash of patient deaths over the course of about two years. And in that case, it was actually the county behavioral health department that paused admissions on involuntary psychiatric patients specifically for about seven months. Okay.

Why did it take two years for them to reach that finding, Joaquin, with regard to Tyler Thatcher Cox? So we found some of these investigations can take a long time for CDPH to complete. It is an issue that lawmakers are aware of. They've tried to rectify it. They're trying to sort of speed up a backlog of cases.

complaints that have been open for some time. But we found that these investigations can just take a while sometimes for the state health department. How big is the backlog? Right now, the last we looked, oh, God, it was hundreds of cases that were open for longer than six months, which is what they consider to be backlogged. And that's just within the psychiatric hospital space. But CDPH is also overseeing nursing homes, hospitals,

Ray writes,

It isn't necessarily that for-profits don't provide good care or that they provide worse care than nonprofit ones or medical hospitals that are county or government run, right? And we've heard some people share experiences at those facilities as well. But do you think that there are some things that are structurally built into a for-profit model that, to Ray's point, feels like maybe they just should not be in certain industries? Yeah.

From the experts we talked to, staffing is usually the greatest cost for a hospital. And so when you are a for-profit facility, some of these companies are publicly traded. They are trying to hit certain growth goals in a given year for their shareholders. Staffing becomes the easiest target. And so...

You know, again, the experts we talked to didn't present it as whether they should or shouldn't be in this field. It is a I mean, there is a great need for more of this type of care. It's whether there should be more guardrails on that. We're talking with Cynthia Dizekas and Joaquin Palomino, investigative reporters for the San Francisco Chronicle. And you are listening to Forum. I'm Mina Kim.

Thank you for this.

important reporting. Thank you, listeners, for sharing these very difficult stories. We really appreciate it. Mira writes, I'm curious how the investigative reporters decided to pursue this topic. Joaquin? Yeah. So we sort of alluded to it. We're in a moment right now of sort of big changes within the state's behavioral health care space.

There are a number of laws that have been implemented specifically to give people more access to care and sort of make people more people eligible to be placed on these involuntary psychiatric holds. Prop one is going to put a lot of money into building out facilities across the spectrum from the acute to the long term to the residential. And so we work.

Sort of at this period in California, it felt like it was worth looking into, you know, as the discussion has really been about expanding access to care, also look at what that care looks like and the quality of care within these facilities. And then, you know, as it sort of always happens with reporting, you start with these sort of broad questions and then you start noticing patterns. And sort of what we noticed almost, not almost, it took us a while, but what we noticed was that

When you look at the deficiency reports, when you look at the state staffing data, when you look at the state spending data, when you talk to patients, when you talk to workers, um,

it felt like these for-profit, many of these for-profit hospitals just seemed to operate differently. And when it came either to how they were staffed or when it came to sort of the serious safety violations within them. And so that's sort of how that became the focus of our reporting. Let's hear actually a clip from the governor talking about his ambitious plans to

to be able to expand mental health care access as a reaction to what he says were the failures of the Reagan administration's deinstitutionalization efforts. We are here at the Reagan State Building. Former governor in 1967 launched many of the reforms that led to the conditions that we're experiencing here today.

efforts around deinstitutionalization, but they never fulfilled the vision of creating the alternative system that ultimately would support community efforts. This is the fulfillment

Of the promotion and promises that were made a half century ago. So this points to what you were saying earlier, Cynthia, about there is a need. We need more of these services. And as a result of failures from conditions, administrations in the past who weren't able to fully operate.

You know, roll out what was necessary to be able to support the well-being of psychiatric patients. So it really is for you as an investigative reporter, just the balancing of the need with robust oversight.

Exactly. And you've heard it from some of the callers, and we definitely got this from the former patients that we have talked to. But for this whole thing to work, there has to be trust there in patients when they are going into a facility that they are going to be taken care of and that things are going to get better. And that needs...

you know, the quality of care that's being provided at, you know, specifically at this moment of time in California with so much attention focused on access. As Joaquin mentioned, the quality really needs to be front and center as well. What will, so there have been two installments in this series. There's a third one on the way. What will the final installment of your series focus on, Joaquin?

So we are really looking just at sort of the oversight of the psychiatric hospitals on how the state responds to, at times, sort of persistent safety violations within facilities. And what are you hoping the impact of your reporting will be? Or have you heard from people after the first two stories were put out?

We've gotten a lot of people similar to the callers on the show who have reached out and shared, you know, similar experiences that they have have been through either as patients or as employees of some of these facilities.

And we are just going to keep sort of monitoring when it comes to any sort of other change or reforms that might come from this reporting. We're just going to continue to monitor that and just see if anything else will come from it. Yeah. I remember after the Acadia reporting came out, the reporter talked about how

There were a number of people who were talking about people being held against their will and facilities at the very moment that this piece came out and that it helped them to better understand their frustration with not being able to get their loved ones out of these facilities.

Anything you would add to that, Cynthia, with regard to the impact that you hope this has with the third installment? Yeah, I mean, I think along those lines, and even from what Alexandra Del Sima, the former worker from Heritage Oaks, said earlier, that when you enter the system, you do so literally in isolation, and you feel like your experiences might just be yours. And our hope is that...

This just helps educate people and also, you know, raises this issue to the fore and lets people know that, you know, this perhaps if they've had bad experiences in these places, they aren't alone in that. That seems to bear out in the data we have seen. And it's disproportionately happening in these for-profit psychiatric hospitals. Right.

The series is called Failed to Death. Cynthia Dizekas is an investigative reporter on it. So is Joaquin Palomino. And they're with the San Francisco Chronicle. And thank you, listeners, for sharing your experiences, your thoughts, and also your questions for our reporters. My thanks to Caroline Smith for producing this segment. You have been listening to Forum. I'm Mina Kim.

Funds for the production of Forum are provided by the John S. and James L. Knight Foundation, the Generosity Foundation, and the Corporation for Public Broadcasting.

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