Riverside County Emergency Treatment Services failing patients and doctors

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Content RIVERSIDE COUNTY EMERGENCY TREATMENT SERVICES FAILING
PATIENTS AND DOCTORS

by

Jessica Roberts

A Thesis Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
MASTER OF ARTS
(PRINT JOURNALISM)

May 2007

Copyright 2007 Jessica Roberts
ii
TABLE OF CONTENTS

Abstract iii
Part One: Patient care lacking at Riverside psychiatric emergency facility 1
Part Two: Doctors unhappy with working conditions at Riverside ETS 10
Sources 19
iii

ABSTRACT

Riverside County’s Emergency Treatment Services is one of only a few
psychiatric emergency rooms in the state, but the facility has not been able to keep up
with the fast-growing population in the county. Seventeen years after it first opened,
doctors and other staff complain that conditions for patients are intolerable.
Overcrowding in the emergency room forces doctors to interview patients in
group areas, compromising patient confidentiality, and patients to sleep on the floor
because there are not enough beds or chairs. Doctors are also concerned about their own
fatigue, as the administration no longer allows psychiatrists on overnight shifts to sleep
when there are no patients to be seen. These concerns have prompted the administration
to plan expansions to the physical space of the facility, but the timeline for those
improvements is in question.
1

PART ONE
Patient care lacking at Riverside psychiatric emergency facility

Riverside County’s Emergency Treatment Services opened in 1990, a state-of-
the-art facility hailed as a “major step forward” for treatment of the mentally ill and one
of a handful of emergency rooms in California exclusively for psychiatric patients.
Seventeen years later, doctors, nurses and other staff at the single-storey building
on County Farm Road in Riverside describe it as a “snake pit” where conditions for
patients are worse than in developing countries.
Administrators say expansions are planned to alleviate the problems, but may not
be completed for up to a year.
Doctors, nurses and technicians complain of a deteriorating facility where
normally private patient interviews must be conducted in group areas and patients often
sleep on the floor. Exacerbating these problems is the fact that psychiatrists’ orders are
countermanded by the nurse manager, putting patients and hospital staff at risk, and
doctors are overworked due to staffing shortages and patient overcrowding.
Several staff blame overcrowding in the Emergency Treatment Services (ETS)
facility, which has not expanded to keep pace with the population growth in Riverside
County and now takes in twice as many patients as it was designed to handle.
As a result, patients are frequently interviewed in the day room common area – a
violation of laws designed to protect patients’ privacy rights. There is only one private
room to interview patients, and regulations say each admitted patient must be seen by a
doctor within one hour of arriving in the emergency room.
2
“It’s very chaotic in there,” said Dr. Wadsworth Murad, a psychiatrist employed
at ETS until September 2006, when he said he was dismissed because he complained
about conditions at the hospital. “It’s very scary for the general public. Add on top of that
someone who’s distraught mentally or intoxicated – it’s a frightening experience. It’s just
not conducive to an environment that would be helpful to you getting better.”
ETS staff must weigh the privacy of the patient against the need to evaluate
patients as soon as they enter the hospital setting. The one private interview room is often
occupied, so psychiatrists, nurses and other staff must interview patients in the group
room.
“The patients do not have private interviews,” said a letter drafted on behalf of
several ETS physicians to be sent to oversight bodies. “They are asked to describe
personal life events like rape, molestation, infidelity and thoughts of suicide in front of a
room full of other patients who at times attempt to join in their personal interview
process.”
“That’s confidential information,” said Theresa Galvez, chief patients’ rights
advocate at the Riverside County Patients’ Rights Office. “It should not be where other
people could hear it... It is non-compliance with the public law.”
The lack of privacy for patient interviews specifically violates HIPAA, (the
Health Insurance Portability and Accountability Act), which some staff call “an unfunded
mandate,” that is a state law enacted without enough financial support to facilitate the
hospital’s following the law.
3

Mental health patients are particularly vulnerable because they are less able to
credibly articulate how they’ve been mistreated and they are less capable of formally
complaining or filing legal actions.
“Mentally ill patients are treated as second class,” said Dr. Hanaa Fam, who has
worked at the county facility for six years. “They’re always labeled or accused of being
manipulative.”
In order to make a claim against the county, patients would have to file against the
particular system, according to Galvez, and then take the system to court if the claim is
denied. She was not aware of any patients from ETS who had filed that kind of claim
against Riverside County.
Jerry Wengerd, director of the Riverside County Department of Mental Health,
acknowledged that patients are sometimes interviewed in group areas, because the space
does not allow for private interviews for all patients.
“State licensing has come out and they have not cited us because they recognize
that we do not have enough physical space,” said Deborah Johnson, assistant hospital
administrator. “The reality is we’ve outgrown the space.”
When the facility opened in 1990, the population of Riverside County was
1,170,413 – a number that has grown by 66 percent to 1,946,419 people in 2005. There is
no other psychiatric emergency facility in the county.
ETS won state and county recognition in the 1990s for the standard of care
provided to patients, including an award in 1996 from the American Psychiatric
Association.
4
In its first years ETS reported that 300-350 patients were seen per month. In 2004
doctors were seeing 900 patients each month. There has been no expansion of the
physical space in that time.
At times there are fewer than 10 patients in the facility. Other days there are as
many as 30 at once. Because of EMTALA, the Federal Emergency Medical Treatment
and Active Labor Act, the hospital is obliged to treat anyone on the premises, and cannot
turn patients away.
Johnson said 90-92 percent of the patients seen at ETS arrive in police custody,
under an involuntary psychiatric hold or “5150,” a section of the state Welfare and
Institutions Code that allows police and other staff designated by the county to take a
person into custody and place them in a facility for up to 72 hours of treatment and
evaluation. No matter how many patients are in the ETS, the hospital cannot close its
doors to law enforcement bringing in 5150s.
One staff member described the ETS as “a meat market,” where she says the
county drops intoxicated, violent or homeless people.
“It should have a capacity, but they don’t,” said psychiatric technician Barbara
Bertrand. “If they gave you a capacity number, they’d have to adhere to it – they don’t
want that.”
The other major concern for ETS patients care is that there are so few beds and
chairs in the crowded emergency room area that those waiting for care regularly sleep on
the floor.
“Sleeping on the floor there are at least two or three of them every night,” said
Murad. “Others would be milling about.”
5

As many as 30 patients are sometimes gathered in the group room and they must
share seven beds, nine chairs and limited bathroom facilities.
“One bathroom, if it’s working,” Bertrand said. “And sometimes no bathroom.”
“Many third world countries offer better treatment of their mentally ill,” said the
psychiatrists’ letter, which also noted that patients often must sleep on the floor. The
letter, which was to be given to the Board of Supervisors, The State Department of
Health Services, the individual HMO and insurance companies and the oversight
committees, was never sent, because its author was fired by the hospital and he felt he
could no longer represent the group of irate doctors.
Although every member of ETS staff interviewed for this story said patients sleep
on the floor, hospital administrators denied the claims. They acknowledged only that the
space is inadequate for the number of patients.
“We try to make sure they have some place to rest,” said Johnson. “Sometimes
the choice is that [sleeping on a chair or the floor] or out on the street.”
Wengerd said the county has a short-term plan to expand into a space adjacent to
the current facility and a long-term plan, both prompted in part by complaints from
psychiatrists and other staff to the state licensing board, the county board of supervisors
and other oversight bodies.
“That problem will change in the new facility because it’s really a matter of
space,” he said.
He hopes the physical space of ETS will be expanded in less than a year, although
he said he had the same hope one year ago.
6
“We’re going as fast as we can go,” he said. “It won’t be another year. I hope it’ll
be six months or eight months.”
A long-term move is planned to a larger facility at the county’s Moreno Valley
medical campus, but will take much longer – likely more than five years.
Meanwhile, inadequate physical space is not the only complaint from doctors
concerned about patient care.
Psychiatrists said one of the biggest concerns they have in dealing with the
administration is that doctors’ orders are often countermanded by nurse manager Anna
Fuzie, a practice that may also have the greatest effect on patient care.
“Doctor’s orders for restraints can be countermanded by nurse managers,” the
letter said. “That unofficial policy has led to an environment in which nurses are afraid to
place violent patients in restraints, where doctors have been told by the Chief of
Psychiatry not to order restraints for patients and where nurses are afraid to follow
doctors’ restraint orders. It is a highly dangerous circumstance and it needs to change.”
Dr. Richard Kotomori recalled an incident in which he ordered restraints for a
patient and then watched as his order was ignored under Fuzie’s supervision. Hospital
administrator Johnson said she witnessed the situation Kotomori described, and she
believed the patient did not require restraint, although she is not a licensed physician.
Wengerd said the hospital wants to discourage the use of restraints as much as
possible, in accordance with recent studies, which he said all point to the negative effects
of restraining patients.
In another case, Dr. Adel Hanna said he ordered an injection for a patient, but
Fuzie gave the patient an oral sedative, which is slower to take effect.
7

Marquez said one patient who was left out of restraints, against a doctor’s order,
fell over and was sent to the emergency room at Riverside County Regional Medical
Center. A CT scan of the patient’s head revealed that he had suffered an epidural bleed,
she said.
Wengerd said he was not aware of the incident.
“What amazed me is that this woman can overrule doctors,” Bertrand said.
“That’s not done anywhere.”
Doctors say patients are also admitted to the emergency room by nurses or
administrators – a direct violation of requirements that doctors sign off on all
admittances.
The administration denied that it was hospital policy for nurses to overrule
doctors or that it was a pattern of behavior in nurses at the hospital.
Doctors are also concerned about compromised patient care because physicians
on night shifts are forced to deal with overcrowding in the emergency room. At night a
single ETS doctor is often alone in the facility, which includes at least 25 patients in the
ETS area, 70 beds in the In-patient Treatment Facility (ITF), and all the patients in the
Children Evaluation Services Unit (CESU) – which can mean as many as 150 patients in
total.
Copies of the October 2006 ETS schedule revealed there was only one doctor
scheduled for 12-hour shifts 16 times in 31 days, and no doctor scheduled for 12-hour
shifts on 10 separate days. Medical Director Dr. Jerry Dennis and chief of staff Dr. Bitin
Patel covered those shifts or had doctors from the ITF or CESU cover the emergency
room on top of their regular duties.
8
The hospital has since hired more physicians to fill the schedule, although those
doctors are sometimes still responsible for more than 100 patients at one time.
Doctors say the medical director directly jeopardizes patient care by creating an
understaffed treatment scenario by driving away physicians with his policies.
“They kept harassing the doctors – doctors walked out,” said Fam. “Others were
pushed out.”
Wengerd said those problems are exaggerated or even caused by the doctors
themselves.
“Most of their complaints were created by them [the doctors],” he said.
Several psychiatrists have left or been dismissed in the last year, staff members
note. Two died in early 2006. One psychiatrist was let go in August 2006 and three others
were released the following month. One of those three was Kotomori, who was told his
“services were no longer needed” two days after he suggested starting a union at a staff
meeting. Another of the three was Murad, who said he was let go one week after he sent a
questioning letter to the county board of supervisors.
“Anybody who has their own mind and who's a little bit independent and stands
up to them, they’re going to let go,” Bertrand said.
Dennis said not a single doctor had been fired, but he would not comment on the
departure of specific individuals because the county is facing two lawsuits from doctors,
with a third pending.
“We just stopped scheduling them,” Dennis said.
9

Since most doctors on staff at ETS were hired on a per diem basis, it is technically
not necessary to fire them, or give any reason or notice before letting them go. The
administration can simply remove a doctor from the schedule.
Dennis said he has hired five new psychiatrists since September and Wengerd
said the ETS is now much different than it was three months ago.
In terms of improving patient care he said, “I don’t think we’re there yet, but I
have real high hopes.”
10
PART TWO
Doctors unhappy with working conditions at Riverside ETS

It was a bed that finally thrust the doctors into open rebellion.
Emergency room shifts are 12 hours long and, especially in the middle of the 8
p.m. to 8 a.m. turn, doctors usually sleep in the break room when there are no patients to
be seen.
When the administration at Riverside County’s psychiatric Emergency Treatment
Services (ETS) announced it would remove the only bed from the break room, the
psychiatrists became outraged.
The bed gone, they catnapped wherever they could find space. Dr. Purificacion
Marquez, a psychiatrist employed at ETS until October 2006, said one colleague even
rolled up in a blanket on the floor.
“I felt like she was like a refugee, a homeless person,” said Marquez, who took a
break inside her car.
Beds in doctors’ break rooms are standard in emergency rooms, according to
former and current hospital administrators. At Patton State Hospital in San Bernardino
County, the doctors not only have a bed, but a bathroom and refrigerator in the break
room.
“The nature of ER services is either very busy or very slow,” said Dr. Wadsworth
Murad, a psychiatrist employed at ETS until September 2006. “Because we all know that
happens, we lie down during a shift to help prevent fatigue.”
One doctor compared ER doctors to firefighters – they are expected to be
11

available when needed, but not to be constantly working while they are at the hospital.
Hospital administrators said that the problem was with doctors, who were
sleeping rather than taking care of patients.
“We’re paying them their full rate and they’d have patients waiting while they’re
trying to sleep,” said Jerry Wengerd, director of the Riverside County Department of
Mental Health. “They were not doing their jobs.”
Doctors denied that patients waited while they slept, and said it was necessary to
take short naps during a 12-hour overnight shift.
Dennis insisted that because ETS doctors were on 12-hour shifts, not 24-hour
shifts, they did not need to sleep. However, most emergency facilities and mental health
facilities do not require 24-hour shifts and still allow doctors to rest when there are no
patients to be seen.
The lack of a bed in the break room was especially a concern in the fall of 2006,
when the schedule left a single physician from ETS responsible for the entire Riverside
facility, which includes at least 25 patients in the ETS area, 70 beds in the In-patient
Treatment Facility (ITF), and all the patients in the Children Evaluation Services Unit.
“One doctor was covering up to 150 patients,” said Dr. Richard Kotomori, who
worked at the facility until he was dismissed in September 2006.
“It’s affecting patient care,” said Marquez. “The workload at Riverside is too
much.”
Murad said fatigue was a concern, that doctors could make mistakes and that the
situation “absolutely” compromises patient care.
“It’s just a matter of time before something goes wrong,” he said.
12
Staffing shortages resulted from the firing and departure of several doctors at the
end of 2006.
“They kept harassing the doctors – doctors walked out,” said Dr. Hanaa Fam,
psychiatrist at ETS for six years. “Others were pushed out.”
Kotomori, Murad and Dr. Adel Hanna were let go in August and September 2006.
Two doctors died in early 2006. Dr. Carolyn Conner took herself off the schedule a
couple months later.
Dr. Jerry Dennis, medical director of the Riverside County Mental Health
Department since August 2006, said not a single doctor had been fired.
“We just stopped scheduling them,” he said.
Since doctors at Riverside work on a per diem basis and paid hourly wages --
$100 per hour for ETS work – they do not technically need to be fired. The hospital can
simply remove doctors from the schedule and inform them that their services are no
longer required.
Doctors are hired by the county on a per diem basis because it is the simplest way
to staff the emergency room. Hiring doctors as civil service employees only works for
full-time employees, while hiring on a contract basis would require the county board of
supervisors to approve each hire individually. The process is so slow that doctors would
generally rather take another job than wait for the necessary approvals.
Per diem hires are paid through funds approved generally for that purpose by the
board of supervisors. It makes the hiring process smoother and faster – but also makes
firing easier.
Not all doctors were forced to leave. Several physicians and nurses, including
13

Marquez, took jobs at Patton Hospital, or were in the process of interviewing for jobs
there. On a staff of a dozen physicians, the effect was certainly felt.
Copies of the October 2006 ETS schedule show only one doctor scheduled for 12-
hour shifts 16 times in 31 days, and no doctor scheduled for 12-hour shifts on 10
additional days.
Dennis said the county has hired five new doctors in the past six months and
Wengerd said the situation at ETS has greatly improved.
“It’s really quite a different place than it was three months ago,” he said.
Although the new psychiatrists are also working on a per diem basis, Wengerd
said the focus is to encourage full-time commitments and what he calls a team approach.
He did not address whether asking doctors to make a full-time commitment to a per diem
contract was feasible.
Wengerd said that the problems last year were created or exaggerated by doctors,
and those doctors are now gone.
“The three or four physicians that were kind of at the heart of this are not here
anymore,” he said.
However, the three doctors who were removed from the facility by the
administration – Kotomori, Murad and Hanna – were well-regarded and had decades of
experience among them.
“We have good records, work history, patient care, and then ‘boom’,” said
Kotomori.
“It’s insulting,” added Murad, who has practiced psychiatry for 20 years and is
chief of psychiatry at Patton State Hospital. He said he received an excellent record
14
report a week before he was released.
All three doctors have filed lawsuits or complaints against Riverside County.
They and other doctors insisted that the bed was only the most recent and the
most egregious offense in a facility where they say they feel like second-class citizens.
ETS wasn’t always like this. When it opened in 1990 the facility was one of only
a few psychiatric emergency rooms in California, in a “state-of-the-art” building. In the
first decade ETS won several awards for patient care.
Several doctors point to the departure of Medical Director Richard Dorsey in
2004 as the beginning of a combative relationship between doctors and administration.
Nowhere was that combative relationship more obvious than in the
administration’s order to remove the break room beds, and the meeting where doctors and
administrators discussed the issue.
Wengerd said the administration believed doctors were sleeping most of the night
shift while patients waited “hours and hours.” He said the doctors’ reaction to the
removal of the bed was surprising.
“I was shocked,” he said. “I’d never seen physicians act like this. It was very
inappropriate, very unprofessional.”
Psychiatrists denied that they slept while patients were waiting – and pointed to
other psychiatric emergency facilities where beds are provided for doctors.
The conflict reached a climax when Dennis called a meeting September 6, 2006.
Dennis said he had a whole agenda to discuss at the meeting, but the doctors
insisted that he address the removal of beds.
According to doctors who attended the meeting, Dennis summarily announced the
15

decision and attempted to move on to other agenda items. The six psychiatrists present
demanded to be told when patient care had been compromised.
Dennis gave no response, repeatedly saying he would not address the issue
further. Kotomori stood up and challenged Dennis, asking for an explanation, growing
louder and more adamant as Dennis refused to respond. Kotomori finally encouraged
other doctors to join him in starting a union.
“Kotomori said, ‘Guys, send me an e-mail and we will try to bring in the union,”
said Marquez. He made this suggestion in front of Dennis and Debra Johnson, assistant
hospital administrator in charge of mental health.
During his next shift Kotomori was summoned to Dennis’ office and asked to turn
in his security badge and keys.
Kotomori has hired a lawyer to file a suit against the county for wrongful
termination.
“If you’re fired for starting a union, that’s illegal,” said Joe Bader, regional
administrator for the Union of American Physicians & Dentists.
Kotomori made an effort to organize a chapter of the UAPD at Riverside so the
psychiatrists would have some power in dealing with administrators.
Unionizing was difficult for the doctors. Kotomori, Murad and other doctors
arranged a meeting on September 29 with Bader and Jorge Rodrigues, a union
representative for the UAPD.
Only four psychiatrists showed up. Those in attendance speculated that others
were too afraid of retribution to do anything against the county. A few weeks later, the
unionizing effort had died.
16
Although Bader said he believed Kotomori had a strong case, there was not
enough effort from the other psychiatrists, especially those still employed at Riverside, to
form a union chapter.
“Most people have other options,” said Kotomori. “And those who don’t are even
less likely to do something... they’re intimidated.”
Psychiatrists say they want better working conditions because it will allow them
to perform their jobs better.
“It’s an example where working conditions of doctors and nurses dovetails with
patient care,” Bader said. “You improve working conditions, you improve patient care.”
Hanna, dismissed one month before Kotomori, has already filed a lawsuit against
the county for wrongful termination. He claims he was dismissed because he was a
patient advocate.
“During the course of his employment at Defendant Medical Center, Plaintiff
became aware of certain conditions, policies and practices, which increasingly placed the
health and safety of the medical patients at risk,” alleges the suit filed by Hanna. The
brief lists problems including overcrowding of patients, inadequate staffing, patients
sleeping on the floor and “hospital management allowing, authorizing and directing non-
medical administrative staff to ignore and disregard the medical directives…issued by the
medical staff.”
Hanna’s departure followed nearly a year of complaints to the Riverside County
Board of Supervisors, office of Inspector General and the office of the Attorney General.
Murad also filed a complaint against the county because he felt he was terminated
for writing a letter to the board of supervisors suggesting that the hospital’s
17

administration might be trying to force a crisis situation.
In his letter to the Riverside County Board of Supervisors, Murad wrote that he
was concerned about patient care, that he had heard the county wanted to privatize, and,
if so, that current doctors would like to bid on the contract too.
Several doctors said they thought the hostile work environment could be a
strategy by the hospital’s administration to create a crisis situation. That status would
allow the county to enter into a no-bid contract for staff, several psychiatrists said. Such a
contract is made after negotiating with only one firm and can be made more quickly than
typical contracts.
Murad talked to Karen Fields, administrator for the board of supervisors, and then
received a letter from the County of Riverside saying, “We are not going to privatize.”
He says he was let go shortly thereafter.
Six months later doctors, nurses and other staff say the environment at the
hospital is still hostile.
“They don’t like camaraderie there, they don’t like people being friendly,” said
one administrative staff member who preferred to remain anonymous because of the risk
of retribution. “They promote a lot of negative things among co-workers... It’s a small
hell.”
But Wengerd claimed the staff is now much improved, full-time commitments
and a team attitude making for better patient care.
“Now we’ve got almost a full schedule of doctors,” he said.
Wengerd said the ETS space will almost double when it’s expanded into an
adjacent in-patient facility, easing the problems of patient overcrowding. Dennis said
18
there are no plans to hire more doctors.
19

SOURCES

Joe Bader, regional administrator for the Union of American Physicians & Dentists
Barbara Bertrand, psychiatric technician
Jerry Dennis, M.D.
Richard Dorsey, M.D.
Hanaa Fam, M.D.
Theresa Galvez, chief patients’ rights advocate at the Riverside County Patients’ Rights
Office

Adel Hanna, M.D.
Deborah Johnson, assistant hospital administrator
Richard Kotomori, M.D.
Purificacion Marquez, M.D.
Wadsworth Murad, M.D.
Jorge Rodrigues, union representative for the Union of American Physicians & Dentists
Jerry Wengerd, director of Riverside County Department of Mental Health

Asset Metadata

Creator Roberts, Jessica (author)

Core Title Riverside County Emergency Treatment Services failing patients and doctors

School Annenberg School for Communication

Degree Master of Arts

Degree Program Journalism (Print Journalism)

Publication Date 04/11/2009

Defense Date 04/02/2007

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Mental Health,OAI-PMH Harvest

Language English

Advisor Cray, Edward (committee chair), Kotler, Jonathan (committee member), Melnick, Glenn (committee member)

Creator Email jessyrob@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-m377

Unique identifier UC1332170

Identifier etd-Roberts-20070411 (filename),usctheses-m40 (legacy collection record id),usctheses-c127-402711 (legacy record id),usctheses-m377 (legacy record id)

Legacy Identifier etd-Roberts-20070411.pdf

Dmrecord 402711

Document Type Thesis

Rights Roberts, Jessica

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Repository Name Libraries, University of Southern California

Repository Location Los Angeles, California

Repository Email uscdl@usc.edu

Abstract (if available)

Abstract Riverside County's Emergency Treatment Services is one of only a few psychiatric emergency rooms in the state, but the facility has not been able to keep up with the fast-growing population in the county. Seventeen years after it first opened, doctors and other staff complain that conditions for patients are intolerable.

Linked assets

University of Southern California Dissertations and Theses