California’s protection & advocacy system

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or 213-213-8000 in Southern CA. TTY 800-719-5798.


Investigations Unit Success Stories: Archive of Past Success Stories

Monitoring Use of Restraint and Seclusion in State Psychiatric Hospitals: DRC’s IU staff monitored the use of restraint and seclusion practices, as well as the pattern of aggressive acts and serious incidents, at state hospitals.  DRC reviewed and analyzed data pertaining to: the use of restraint and seclusion on patients; restraint/seclusion related injuries to staff and patients; injuries to patients and staff from patient aggressive acts; restraint or seclusion injuries or deaths reported to DRC; and other serious incidents suggestive of criminal abuse reported to DRC (unexpected/suspicious deaths, sexual assault allegations involving staff, physical abuse reported by staff that was in turn reported to local law enforcement).  

DRC concluded that the use of restraint and seclusion was increasing in most state hospitals, and that there was an increase in documented staff injuries during incidents of restraint or seclusion.  IU staff noted that patient to patient aggressive acts, and patient to staff aggression has decreased.  The monitoring raised the following issues: data posted on the Department of State Hospitals (DSH) website is cumbersome to review and unreliable.  Further, there are questions about the consistency of reporting across DSH facilities, and questions about how DSH is using the data collectively.   DRC met with one responsive state hospital director to discuss these issues.  DRC plans to meet with DSH administration in 2014.

Room and Board Coalition Model Spreads: Disability Rights California have investigated squalid conditions at a number of unlicensed room and board homes serving adults with psychiatric disabilities across the state.  One provider in San Bernardino County was housing residents with psychiatric disabilities in chicken coops which had been converted into barracks-style housing.  Residents were using buckets as toilets.  Meals, cooked in a makeshift open-air “M.A.S.H. type” kitchen, were served to residents on outdoor picnic tables, rain or shine.   

Conditions were similar at an unlicensed home in Sacramento County where a portable, plastic “Tuff Shed” with a two burner propane camping stove set up in the yard served as the facility’s kitchen space.  Dirty dishes were stacked on a table in the yard to be cleaned with a garden hose that was lying nearby on the ground.  Debris was littered across the premises. In both cases, because the facilities are unlicensed, county and state officials were slow to respond to resident complaints and lack enforcement authority. 

Disability Rights California assisted local advocates to establish a peer-driven advisory coalition to improve conditions in these unlicensed facilities.  This coalition provides the resources, such as an online listing of good homes, conflict resolution processes, and unannounced on-site inspections to ensure that consumers are protected, empowered, and can make informed decisions about where and with whom they live. 

Presentations by Disability Rights California of this model at state-wide mental health conferences have been “standing room only” as advocates and consumers clamor for models of addressing this issue of the limited availability of suitable housing.  Disability Rights California has published a consumer friendly publication about housing rights.

Abusive Restraint Practices in IMD:  Disability Rights California confirmed a pattern of excessive and abusive restraint practices at a large locked nursing home serving individuals with psychiatric disabilities.  Most of the residents lacked insight into their serious condition and were placed at the facility by publicly appointed conservators or the courts.  Several years earlier, Disability Rights California had negotiated an access agreement with the facility’s corporate entity when denied access to records and residents after receiving numerous reports and then witnessing incidents of resident abuse. 

Residents described being restrained face forward into the wall and then suspended in the air several feet off the ground.  Residents were then suddenly dropped, causing them to fall to the floor.  Staff then lifted the residents up, slamming them again against the wall and suspending them several feet off the ground only to then drop them again.  This sequence of suspended wall restraint and then dropping was repeated multiple times during each restraint event.  Residents also described staff kicking their legs so far apart during wall restraints as to cause lasting groin pain.

Facility staff did not dispute the residents’ description of the restraint techniques but claimed they were necessary and complied with the restraint training program principles, a claim disputed by the training program.  Disability Rights California providing counseling to residents on how to file complaints with the department of state licensing.  Disability Rights California also met a number of times with facility and corporate leadership.  Eventually, all staff were retrained in proper restraint techniques, the facility administrator was replaced, and involved staff were terminated.