U.S. v. Cal.

i

I l l l l II I I l l l III) III I IIM ••Ill l i l i l III

-«|fc

I
IDICK THORNBURGH jJOHN R. DUNNE

ORIGINAL
FkEO

2

'ARTHUR E. PEABODY, JR.

IBENJAMIN P. SCHOEN

SEP i 3 1993

3

iEDWARD A. STUTMAN

ROBERT H. STERN

RICHARD V.'

4

United States Department of Justic

|ClVll Rights Division

5

jSpecial Litigation Section

6

|320 First Street, N.W. Washington, D.C. 20530

7

(202) 514-6247

WILLIAM T. MCGIVERN

8

United States Attorney

450 Golden Gate Avenue

9

San Francisco, CA 94102

(415) 556-1126

10 Attorneys of the United States

11

of America

12 IN THE UNITED STATES DISTRICT COURT
13 FOR THE NORTHERN DISTRICT OF CALIFORNIA

15

UNITED STATES OF AMERICA,

)

16

C 90 2&41 Plaintiff,

17

v.

18

STATE OF CALIFORNIA; GEORGE DEUKMEJIAN, ) Civil Action No

Governor of the State of California; )

19

CALIFORNIA DEPARTMENT OF MENTAL HEALTH; )

LYNN WHETSTONE, Acting Director,

)

COMPLAINT.

20

California Department of Mental Health; )

Civil Rights

RICHARD P. FRIDAY, Executive Director, )

21

Napa State Hospital,

)

)

22

Defendants.

)

23

24

THE UNITED STATES OF AMERICA alleges:

25

1. This action is brought by the Attorney General, on

26

behalf of the United States, pursuant to the Civil Rights of

Page 1 — Complaint

^Institutionalized Persons Act of 1980, 42 U.S.C. § 1997 et seq.,

2

!jto enjoin the named defendants from depriving persons residing

iii

3

;at the Napa State Hospital (NSH), Imola, California, of rights,

4

jjprivileges or immunities secured or protected by the Constitution

li

5

of the United States.

6

JURISDICTION

7

2. This Court has jurisdiction over this action under

8

28 U.S.C. § 1345.

9

3. The United States has standing to maintain this action

10

pursuant to 42 U.S.C. § 1997a.

11

4. The Attorney General has certified that all the pre-

12

filing requirements specified in 42 U.S.C. § 1997b have been met.

13

The certificate of the Attorney General is appended to this

Complaint and is incorporated herein.

5. Venue in the Northern District of California is proper

lfi

pursuant to 28 U.S.C. § 1391. The claims herein arose in said

17

District.

18

PARTIES

19

6. Defendant STATE OF CALIFORNIA is a "State" within the

20

meaning of 42 U.S.C. § 1997. The State of California owns and

21

operates NSH.

22

7. Defendant GEORGE DEUKMEJIAN is the Governor of

23

California, and, in this capacity, heads the Executive Branch

24

of State government and, among other duties, reviews and approves

25

budget requests submitted by Executive Branch agencies. He

26

Page 2 — Complaint

1

selects and appoints the Director of the California Department of

2

Mental Health.

3

;

8. Defendant CALIFORNIA DEPARTMENT OF MENTAL HEALTH (DMH)

i

4

.[is responsible for the operation, control and administration

5

;jOf NSH.

Ij

6
I

9. Defendant LYNN WHETSTONE is the Acting Director of DMH,

7
land, in this capacity, exercises administrative control of and

8
i|responsibility for NSH, with authority to direct DMH resources to

I!

9

iiNSH in support of NSH's maintenance and staffing needs as well as

)i

10

''\ its medical, treatment and rehabilitative care programs.

•\

11

I;

10. Defendant RICHARD P. FRIDAY is the Executive Director

12

!of NSH and, in this capacity, has the responsibility for and

!|
13

|jcontrol of the daily operation of NSH.

14

11. The individual defendants named in paragraphs 7, 9 and

15

lfi

I"10 above are officers of the Executive Branch of the State of

California and are sued in their official capacities.

17

FACTUAL ALLEGATIONS

18

12. NSH, a State mental health facility administered and

19

!operated by DMH, is an institution as that term is defined in

20

42 U.S.C. § 1997(1)(A), (B)(i), and is located in Imola,

!

21

'California, within the Northern District of California.

22

:

13. Patients residing at NSH include mentally ill and

i

23

i
(handicapped citizens.

24

14. Defendants are legally responsible, in whole or in

25

part, for the operation of and conditions at NSH, as well as for

26

the care persons confined therein.

I

Page 3 — Complaint

||

15. At all relevant times, defendants or their predecessors

2 ij in office have acted or failed to act, as alleged herein, under
!|
3
i color of State law.
4
16. Defendants have failed and are continuing to fail to
5
provide patients residing at NSH with adequate medical and
6
psychiatric care and treatment necessary to ensure that they are
7
free from unreasonable risks to their personal safety and
8
unreasonable use of bodily restraints.
9
17. Defendants have failed and are continuing to fail to
3D
ensure that there is an adequate number of sufficiently trained
11
staff to render and implement professional judgments regarding
32
necessary care, medical services and psychiatric treatment to NSH
13
patients.

18. Defendants have failed and are continuing to fail to

ensure appropriate and timely review and evaluation of the

medical status and treatment needs of patients who reside at NSH.
17
19. Defendants have failed and are continuing to fail to
38
maintain professionally based recordkeeping and record review
39
systems to ensure that patient records contain accurate, up-to-
20
date, relevant and readily accessible information as is necessary
21
to enable staff to exercise professional judgment regarding
22
medical and psychiatric care and treatment decisions.
23
20. Defendants have failed and are continuing to fail to
24
ensure that medications are prescribed and administered to
25
persons confined at NSH pursuant to the exercise of professional
26
judgment by appropriately qualified staff.

Page 4 — Complaint

!

21. Defendants have failed and are continuing to fail

< to ensure that bodily restraints are administered to persons

3

|confined at NSH only pursuant to the exercise of professional

4

judgment by appropriate qualified professionals and are not used

5

as punishment, in lieu of treatment, or for the convenience of

6

staff.

7

22. Defendants have failed and are continuing to fail

8

to employ effective monitoring and quality assurance measures

9

necessary to identify and correct the deficiencies described

10

in paragraphs 16 through 21.

11

VIOLATIONS ALLEGED

12

23. The acts and omissions described in paragraphs 16

13

through 22 constitute patterns or practice of resistance to the

14

full enjoyment of rights, privileges or immunities secured or

protected by the Constitution of the United States, and deprive

16

persons confined at NSH of such rights, privileges or immunities.

17

24. Unless restrained by this Court, defendants will con-

IS

tinue to engage in the conduct and practices set forth in

19

paragraphs 16 through 22 above that deprive persons confined to

20

NSH of rights, privileges or immunities secured or protected by

21

the Constitution of the United States, and cause irreparable harm

22

to NSH patients.

23

PRAYER FOR RELIEF

24

25. WHEREFORE, the United States prays that this Court

25

enter an order permanently enjoining defendants, their agents,

26

employees, subordinates, successors in office, and all those

Page 5 — Complaint

acting in concert or participation with them from continuing the

acts, practices or omissions at NSH set forth in paragraphs 16

3

i!through 22 above, and to require defendants to take such action

ii

4

as will provide constitutional conditions of confinement to NSH

5

residents.

6

26. The United States further prays that this Court grant

7

such other and further equitable relief as it may deem just and

8

proper.

9

Respectfully submitted,

ID

11

12

DICK THO

Attorney

13

the Un

16

WILLIAM T. MCGIVEl

United States Attorney

17

Northern District of

California

IS

19

20

21

22

23

24

25

26

R. DUNNE fsistant Attorney General Civil Rights Division
ARTHUR E. PEABODY, Chief Special Litigation Section
BENJAMIN P. SCHOEN Deputy Chief Special Litigation Section
Page 6 — Complaint

3

EDWARD A. STUTMAN

ROBERT H. STERN

4

Attorneys

U.S. Department of Justice

5

Civil Rights Division

Special Litigation Section

6

7

8

9

30

U

12

13

14

16 17 18 19 20 21 22 23 24 25 26

Page 7 — Complaint

 </s> , - , ' - . - /"i*'iU1!

LANISL E. LUNGREN, Attorney General cf the State of California
STEPHANIE WALD Deuuty Attorney General
RALPH M. JOHNSON, State Bar No. 52509 Deputy Attorney General
50 F r e m o n t S t r e e t - S u i t e .300 San Francisco, California 94105-2239 Telephone: (415)"356-6382

Attorneys -foar Defendants

_

-

•

•

•

-

-

'

Qtyr-*.
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.••,'••••'•"

8

UNITED STATES DISTRICT COURT

9

NORTHERN DISTRICT OF CALIFORNIA

10

UNITED STATES OFAMERICA,

12

Plaintiff,

13

v:

14 STATE OF CALIFORNIA, et.

) No. C90-2641 EFL
) ) MEMORANDUM IN SUPPORT OF ) MOTION TOTERMINATE CONSENT ) DECREE

Defendants.

17

3y Consent Decrse entered as an Order cf theCourt on

18 September 17, 1990 andmodified b y Stipulation adopted o n August

19 30, 1991, and December 13, 1994 theparties agreed t o , and the

20 Court ordered, a process foraddressing conditions of treatment

21 and habitation at Napa State Hospital (NSH), a state operated

22 psychiatric facility located in-Intola, California.

23

Pursuant to Section VII of theConsent Decree and

24 paragraph 4 of the stipulated order of December 13, 1994, unless

25 there is objection b y the United States, when defendants have

-26- fully and"faithfully implemented allprovisions of the Consent

27 Decree asmodified andplans submitted thereto, the injunctions

28 entered herein shall, upon defendants application, b e dissolved,

MEMORANDUM IN SUPPCRT OF MOTION TO TERMINATE CONSENT DECREE
1.

judgment shall be discharged, jurisdiction shall be terminated

and the case closed and .dismissed with prejudice.

Defendants have fully and faithfully implemented all

provisions of the Consent Decree, as modified, and plans

submitted thereto. By letter dated Kay 24, 1995 the United

States has informed defendants it will not oppose dismissal of

this matter.

:"' It is therefore requested the Court approve the order

dismissing this matter.

10 Dated: May 30, 1995 11 12 13 14 15 15 17 A:\NSHMCTiO. 18

Respectfully Submitted
DANIEL E. LUNGREN, Attorney General of the State of California
f 1 , ...
RALPH JOHNSON Deputy Attorney General Attorneys for Defendants

19 20 21 22

23 24 25 2S 27 28

MEMORANDUM IN SUPPORT OFMOTION TOTERMINATE CONSENT DECREE
2.

 </s> i ROBERT H. STERN | DAVID DEUTSCH J Senior Trial Attorneys
U.S. Department of Justice 3 Civil Rights Division ''
Special Litigation Section 4 P.O. Box GS40Q
Washincton, D.C. 20035 S (202) 514-5250

• ?-•_.?-

6 Attorneys for Plaintiff

J •:' '

7

UNITED STATES DISTRICT C0DRT.7;> :^ ;:;':....l;.v7, . _ 8

FOR THE NORTHERN DISTRICT OF CALIFORNIA '

9

"•-.V""

10 UNITED STATES OF AMERICA,

11

Plaintiff

12

v.

13 STATE CF CALIFORNIA, ec al. ,
14 Defandancs.
15

NO. C-90-2S41 EFL
STATEMENT CF NON-OPPOSITION

IS

17

This is to advise the Ccur~ that the United Staces of

13 America, plaintiff in the above-caption action, dees net oppose

19 defendants' Mccicn to Terminate Consent Decree.

20

Respectfully submitted,

21

22

23

MICHAEL _J._ YAMAGUCHI United States Attorney

24

Northern District of California

25

(kd
ROBERT H. STERN DAVID DEUTSCH Senior Trial Attorneys U.S. Department of Justice

26

May..21, 1595 Wasm."-cten., u. C.

STATEMENT OF NCN-OPPOSITION

DECLARATION OF SERVICE BY MAIL
Re: United States v. State of California, et al. U.S.D.C. fN.D. CaU No. C90-2641 EFL
I, Janie White, declare that I am over 18 years of age, and not a party to the within cause; my business address is 455 Golden Gate Avenue, Suite 7000, San Francisco, California 94102-3658. I served a true copy of the attached
1. ORDER OF DISMISSAL
2. MOTION TO TERMINATE CONSENT DECREE
3. MEMORANDUM IN SUPPORT OF MOTION TO TERMINATE CONSENT DECREE
on each of the following, by placing same in an envelope (or envelopes) addressed (respectively) as follows:
Robert H. Stern Senior Trail Attorney Special Litigation Section Department of Justice P.O. Box 66400 Washington. D.C. 20035
Each said envelope was then, on June 9. 1995. sealed and deposited in the mail in San Francisco, California, the county in which I am employed, with :he fees thereon fully prepaid. Executed on June 9, 1995, at San Francisco, California.
I declare under penalty of perjury that the foregoing is true and correct.
JANIE WHITE DSM-1 (Rev. 1991)

 </s> ATTORNEY GENERAL—OFFICE COPY

DANIEL E. LUNGREN, Attorney General of the State of California
STEPHANIE WALD Deputy Attorney General
RALPH M. JOENSON, State Bar No. 52509 Deputy Attorney General
50 Fremont Street Suite"300 San Franciscor California 94105-2239 Telephones (415J.-355-5382
Atcomeys- for?" Defendants

O/-;,-..,. p" /"','*--^V..
* -^ £~" //,,,
Ov"';;;'KS'-, ^'C.o.^ " '^-i
.,.••-.•'./,-'•.-->.

8

UNITED STATES DISTRICT COURT

9

NORTHERN DISTRICT OF CALIFORN

10

11 UNITED STATES OF AMERICA,

) No. C90-2641 SFL

12

Plaintiff,

) MOTION TO TERMINATE CONSENT

) DECREE 13

) 14 STATE OF CALIFORNIA, et. al., )

15

)

Defendants.

)

IS

17

Pursuant to Rule 60(b) of the Federal Rules of Civil

13 Procedure and the Consent Decree herein, as modified on December

19 13, 1994, sta-a defendants move to terminate the Consent Decree

20 on the grounds the judgment has been satisfied. Filed herewith

21 is zhe Statement of Non-opposition to the granting of this motion

22 from plaintiff, United States of America.

23

24

25

25

28
MCTICN TO TERMINATE CONSENT DECREE

Wherefore, state defendants respectfully request the

Court grant this motion .to Terminate the Consent Decree.

Dated: June 1, 1995

4

..,,..•;.,. .

Respectifully Submitted

5

_y:•;'•'

.,:_•"' S

DANIEL E. LUNGREN Attorney General State of
California

7

3

RALPH M. JOHNSON

Deouty Attorney General

9~

Attorneys for Defendants

10

11

12

13

14 15

16 17 13 19 20 21 22 23 24 25 26 27 28

MOTION TO TERMINATE CONSENT DECREE
2.

 </s> U.S. v. Cal.

• - m^ - ^ * ^ F JJ ' A *^ IHHII HHI Illll

1 DANIEL E. LUNGREN, Attorney General of the State of California
2 STEPHANIE WALD Deputy Attorney General
3 RALPH M. JOHNSON, State Bar No. 52509
Deputy Attorney General 4 50 Fremont Street Suite 300
San Francisco, California 94105-2239 5 Telephone: (415) 356-6382

J(j.

6 Attorneys for Defendants

v_-..;/; •/' .

7

8

UNITED STATES DISTRICT COURT

9

NORTHERN DISTRICT OF CALIFORNIA

10

II UNITED STATES OF AMERICA,

) No. C90-2S41 EFL

)

12

Plaintiff,

) ORDER OF DISMISSAL

13

)

;

v.

)

14 STATE OF CALIFORNIA, et. al. , )

)

15

Defendants.

)

16

)

)

17

Pursuant to the Consent Decree herein, as modified,

13

upon the full implementation of the requirements thereof, the

19

injunctions issued herein may be dissolved, the judgment

20

discharged, jurisdiction terminated and the case dismissed with

21

prejudice and closed.

22

The defendants have now fully implemented the

23

requirements of the Consent Decree, as modified, and the United

24

States has no objection to the dismissal of this action.

25

IT IS THEREFORE ORDERED the injunctions issued herein

26

are dissolved, the judgment is discharged, jurisdiction is

27

28

CRDER CF DISMISSAL

1 terminated and the matter is dismissed with prejudice.

2

3 Dated: 4 5

EUGENE F. LYNCH United States District Judge

6 A:\NSH0RDE3

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

OHOER OF DISMISSAL
2.

 </s> '.. '

i
i1,

i-

-· I

"

1

DICK THORNBURGH

2

iJOHN R, DUNNE
ARTHUR E. PEABODY, JR.

jlBENJAMIN P. SCHOEN

3

I1 EDWARD A. STUTMAN ROBERT H. STERN

4

junited States Department of Justice

s

I Civil Rights Division
I Special Litigation Section

320 First Street, N,W.

6

C.,, IV;:; I Washington, D. c. D 1 (202) 514-6247

f1 2053.Q.. _,,, [!;;;

.;,

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7 8

JJ\K s~~t:;Gi~:ney SEe, I 3 1990,

450 Golden Gate Avenue

·~

9

San Francisco, CA 9410:RICHARO W. WIEKJN

I
1

( 415)

556-1126

CLERK, U.S. DISTRICT COURT N01THERN G1ST:'.!CT OF CAUFCRN1A

lO

I Attorneys of the United States

11

of America

l2

UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA

l3

I, UNITED STATES OF AMERICA,

)

V14

I

11

Pla~~tiff,

C 9 (}l

16 I STATE OF CALIFORNIA; GEORGE DEUKMEJIAN, ;

2641 EFL
Civil Action No,

l7

Governor of the State of California;

)

.CALIFORNIA DEPARTMENT OF MENTAL HEALTH; )

18

LYNN WHETSTONE, Acting Director,

)

California Department of Mental Health; )

19

RICHARD P. FRIDAY, Executive Director, )

'Napa State Hospital,

)

_________________ 20

)

Defendants. 21

) )

22

CONSENT DECREE

23

Jntroduction

24

1. This case was instituted by the

25

1990, pursuant to the civil Rights of Institutionalized Persons

26

IAct ("the Act"), 42 U.S.C. § 1997 et seq.

Page 1 -- Consent Decree

1

2. This Court has jurisdiction over"this action pursuant to

2

28 u.s.c. § 1345.

3

3, Venue in the Northern District of California is proper

4

pursuant to 28 u.s.c. § 1391, insofar as all claims set forth in

5

'plaintiff's Complaint arose in said District.

6

4. The United States is authorized to institute civil

7

actions, under 42 U.S.C. § 1997a, and has met all prerequisites

8

for the initiation of such action prescribed by the Act.

9

5. Defendants are the State of California, the California

10

Department of Mental Health and the following individuals who

11

are sued in their official capacities: the Honorable George

l2

,Deukmejian, Governor of the State of California; Lynn Whetstone,

13

Acting Director of the California Department of Mental Health;

14

and Richard P. Friday, Executive Director, Napa State Hospital.

15

6. Individually-named defendants have authority and

16

responsibility for the operation of Napa State Hospital (NSH),

17

Imola, California, and are officers of the Executive Branch of

l8

·the State of California.

l9

7. On July 17, 1985, the Attorney General of the United

""

,States, by and through the Assistant Attorney General, Civil
'

21

Rights Division, notified the Governor of California, the

22

Attorney General of California and the Executive Director of NSH

23

'of his intention to commence an investigation of alleged unlawful

24

conditions of confinement at NSH, pursuant to the Act.

25

8. On May 28, 1986 1 following a thorough investigation, the

26

1 •

Attorney

General,

by

and

through

the Assistant

Attorney

General,

Page 2 -- Consent Decree

I I
I

1

civil Rights Diyision, informed the Governor of Cali.fornia, the

2

Attorney General of California, and the Executive Director of NSH

I.

! .

3

:of the alleged conditions that were depriving persons residing in

'

4

or confined to NSH of rights, privileges or i:-:1munities secured or

s

protected by the Constitution of the United States, the facts

6

supporting the alleged conditions and the minimum measures which

7

:he believed would remedy the conditions and pattern or practice

8

, of resistance to the full enjoyment of those rights, privileges

•

or immunities .

JD

9. On November 20, 1989, following additional investigative

11

tours of NSH, the Attorney General of the United States, by and

l2

through the Acting Assistant Attorney General, Civil Rights

l3

Division, again informed the Governor of California, the Attorney

lA

General of California, and the Executive Director of NSH that

lS

persons residing in or confined to NSH were being subjected to

16

1conditions that deprived them of rights, privileges or immunities

I

l3

secured or protected by the Constitution of the United States.

l8

10. The parties agree that the care, confinement and

19

treatment of residents at NSH implicate rights of these residents

20

I which are secured and protected by the Constitution of the United

21

: States. The parties entering into this Consent Decree recognize

22

, these constitutional interests and, for the purpose of avoiding

23

i protracted and adversarial litigation, agree to the provisions

24

set forth herein.

25

11. In entering this Consent Decree, defendants do not

26

; admit to any violation of law and this Consent Decree may not be

Page 3 -- Consent Decree

1

,1used by the United States -as evidence of liability in any other

2

!proceeding.

3

12. The provisions of this Consent Decree are a reasonable,

4

,.lawful and fundamentally fair resolution of this case.

s

13. This Consent Decree shall be applicable and binding

r f

6

upon all parties, their officers, agents, employees and

'

7

successors.

8

I. DEFINITIONS

•

As used in this Consent Decree, the following definitions

JD

shall apply -

11

A. Physician: A medical doctor licensed to practice

12

medicine.

13

B. Psychiatrist: A physician who either is certified by or

14

is eligible for certification by the American Board of Psychiatry
1

1S

:and Neurology or who has successfully completed an approved

16

! residency program in psychiatry and upon completion of post-

l:7

residency requirements will become eligible for examination for

18

such certification.

19

C. Psychologist: A person who has attained at least a

20

masters degree in the field of psychology.

21

o. Direct Care Worker: Staff, including psychiatric

22

technicians, who are immediately responsible for implementing

23

specific therapeutic procedures, techniques and treatments, for

24

administering medications, or for providing other care or treat-

2S

ment to residents. Persons performing housekeeping and/or

26

1' custodial functions are not included within this category.

Page 4 -- Consent Decree

I

1

E. Qualified Professional: A person competent, whether

2

;'by education, training or experience, to make the particular

3

decision at issue.

1-,

4

F. Professional Judgment: A decision by a qualified

5

professional that is not such a substantial departure from

6

,accepted professional opinion, practice or standards as to

7

demonstrate that the person responsible did not base the

8

'decision on such professional opinion, practice or standards.

9

G. Bodily Restraints: (1) Any physical or mechanical

lJ)

device used to restrict the free movement of a resident or the

11

;movement or normal function of any portion of a resident's body,

l2

excluding those devices prescribed in writing by a physician to

13

1be used only to provide support for the achievement of functional

14

'body position or balance and devices used for specific medical

15

1and surgical (as distinguished from behavioral) treatment; and

16

(2) chemical substances used solely for the purpose of con-

l:7

trolling the behavior of a resident, and not for treatment

l8

purposes.

19

H. Seclusion: Placement of an individual alone in a locked

""

room or a room from which the resident is physically prevented

21

from egress.

22

I. Treatment: Therapeutic steps and activities, including

23

psychological and psychiatric treatment and medication, deter-

24

mined by qualified professionals consistent with professional

25

judgment to be necessary to protect a resident from unreasonable

26

Page 5 -- Consent Decree

--
l 2 3 4 5 6 7 8 9 lD ll 12 l3 l4 15 16 l:7 l8 J9
20 2l 22
2:3 24 25
26

Ii
I'I
ii :1
'jrisks to personal safety and necessary to enable a residen_t to.
,,!function free from undue bodily restraint.
::
J. State: The Executive Branch of the Government of the
'
[state of California, specifically including the Governor of the State of California, the California Department of Mental Health, the administration of NSH and any and all of their officials, agents, employees and the successors in office of such officials, agents or employees.
PURPOSES AND OBJECTIVES The parties to this action stipulate and agree that the purposes and objectives of this Consent Decree are to accomplish as promptly as practicable the following conditions at NSH in order to ensure that residents at the facility are accorded 1rights, privileges or immunities secured or protected by the Constitution of the United States: A. Treatment by qualified professionals which is designed to reduce or eliminate unreasonable risks to personal safety or unreasonable use of bodily restraints must be afforded to all residents who it is determined by qualified professionals are in need of such treatment in order to reduce or eliminate such risks. B. That degree of care must be provided which is suf'ficient to protect all residents from unreasonable risks to their personal safety by the conduct of staff and of other residents 1
i and from the unreasonable use of bodily restraints.

Page 6 -- Consent Decree

1

C. Adequate medical care.must be available to all residents

2

pursuant to the exercise of professional judgment by qualified

3

professional staff.

4

D. Psychotropic and other medications must be prescribed

5

and administered to residents pursuant to the exercise of

6

professional judgment by qualified professionals and shall not

7

be used as punishment, for the convenience of staff or for

8

'purposes other than treatment.

9

E. Bodily restraints and seclusion, when appropriate, must

10

be administered safely and pursuant to the exercise of profes-

11

sional judgment by a qualified professional.

l2

F. The physical environment of NSH shall be maintained to

13

•ensure that it poses no unreasonable risks, including fire safety

14

risks, to the personal safety of residents.

15

These purposes and objectives shall be achieved at NSH by

16

implementing the requirements set forth in Parts III and IV, and

17

by developing and implementing the plans described in Part V of

l8

this Consent Decree.

i

19

i rrr. MEASURES REQUrRING IMMEDIATE ACTrON

20

A. Medication Practices

21

Psychotropic medications and other medications shall be

22

prescribed and administered to residents only pursuant to the

23

exercise of professional judgment by a qualified professional.

24

To this end, within 60 days, the state shall:

2S

1. Review the record of each resident receiving

26

psychotropic medication and ensure that the medication

Page 7 -- Consent Decree

1

is appropriate in type and dosage for· (a) the resident's

2

mental illness diagnosis and (b) the resident's "problem

3

list" appearing in the record.

•

2. Evaluate each resident receiving psychotropic

s

medication for drug-induced side effects, including tardive

6

dyskinesia.

7

3. Review the record of each resident receiving

8

Haloperidol in both oral and decanoate forms to ensure

9

that physicians/psychiatrists add both dosages to deter-

l!l

mine whether maximum daily dosages are being exceeded.

ll

4. Ensure that professional judgment is exercised by

12

qualified professionals when psychotropic medication is pre-

13

scribed and/or administered to a resident on a PRN ("as

lA

needed") basis, especially when the medication so prescribed

l.5

and/or administered is from the same class as other psycho-

l.6

tropic medication being prescribed and/or administered to

,.,

that resident.

lB

B, Restraint and Seclusion

19

Bodily restraint and seclusion are to be administered only

20

ipursuant to the judgment of a qualified professional. To this

21

end, within 60 days, the State shall:

22

1. Revise guidelines to ensure that (a) during the day

23

shift, a physician completes a clinical assessment of a

24

resident within one hour after the resident has been placed

25

in restraint or seclusion pursuant to a verbal order; and

26

(b) during the evening and night shift, a physician performs

Page 8 -- Consent Decree

1

a clinica_l assessment of a resident within two hours after

2

I

3

the resident has been placed in restraint or seclusion pursuant to a verbal order.

4

IV. STAFFING

5

A. By no later than one year from the date of entry of this

6

Consent Decree, the State shall ensure that a sufficient number

7

of physicians, licensed practical nurses, psychologists and

I

8

'direct ca!:'e workers are employed and an duty to provide direct

•

care at NSH to ensure attainment and consistent maintenance of at

10

least the ratios of staff-to-residents and of other personnel

11

delineated below, each day of the week:

l2

1. Physicians

1:100

13

2. Psychologists

l: 30

14

3. Direct Care Workers

{excluding: the "charge

15

nurse,,; the person who

dispenses medication

16

during the shift; and

registered nurses,

lj'

except to the extent

that the number of

18

registered nurses

exceeds the number

l9

required by Part

IV, paragraph c,

20

below) .

21

a. 1st shift

1:8

22

b. 2nd shift

1:8

23

c. 3rd shift

1:12

24

B. By no later than two years from the date of entry of

25

this Consent Decree, the State shall ensure that a sufficient

26

number of psychiatrists are employed and on duty to provide

Page 9 -- Consent Decree

I

. ,,----

1

direct care at NSH to ensure attainment and consistent mainte-

2

nance of at least the following ratios, each day of the week:

3

1acute care, 1:15; adolescent care, 1:20; and continuing care,
!

4

1: 28.

5

1. In addition to the 51 psychiatrists currently at

6

Napa, the state shall hire or otherwise obtain the services

7

of: (a) eight psychiatrists, by no later than one year from

8

the date of entry of this Consent Decree; and, (b) by no

•

later than two years from the entry of this Consent Decree,

lD

all additional psychiatrists required to fulfill the

11

requirements of Part IV, paragraph B.

12

C. By no later than three years from the date of entry of

l3

, this Consent Decree, the State shall ensure that a sufficient

lA

,number of registered nurses are employed and on duty to provide

;

15

i direct care at NSH to ensure attainment and consistent mainte-

16

nance of at least one registered nurse, per unit, per shift, each

J:7

day of the week.

1. In addition to the 161 nurses currently at NSH,

19

the State shall hire or otherwise obtain the services of:

20

(a) 20 registered nurses, by no later than one year from

21

the date of entry of this Consent Decree; (b) an additional

22

25 registered nurses, by no later than two years from the

23

entry of this Consent Decree; and, (c) by no later than

24

three years from the entry of this Consent Decree, all

25

additional registered nurses required to fulfill the

26

requirements of Part IV, paragraph C.

Page 10 -- Consent Decree

1

D. Within six months of the entry of this Consent Decree,

2

'no less than 40 clerical staff will be employed to provide

3

!Jprofessionals and direct care workers with support in completing

11

4

:required paperwork, typing and other administrative functions.

s

E. Within one year of the entry of this Consent Decree, no

6

less than two physicians, one of whom shall be a psychiatrist and

7

!the other a professional qualified to provide primary medical

8

care to residents, shall be physically present and on duty at NSH

•

during the night and evening shifts .

lJl

F. At the State's discretion, the ratios may be attained by

ll

'hiring additional staff or by reducing the resident population at

l2

NSH. The State agrees that, if it decides to reduce the popula-

13

tion of the hospital by discharging residents, the determination

l.4

1as to which residents shall be discharged shall be made by

I

15

qualified professionals.

I

l.6

V. PLANS

J:7

A. In addition to the requirements specified above, the

l8

:State agrees to file with the Court and serve on the United

19

:States not later than 90 days from the date of entry of this

20

· Decree by the Court its plan(s) for implementing the Decree.

21

l In its plan(s), the State shall set forth the following:

22

1. The steps that the State will take to meet the

23

staff-to-resident ratios required under the terms of this

24

Decree. Appropriate steps may include release of residents,

25

changes in personnel policies, hiring standards and employ-

26

ment practices, adjustments in salaries or pay levels,

Page 11 -- Consent Decree

",', -

I
i•I

1

'

2

3

4

5

6

7

8
•
10

ll

12

13

1A

15

1.6

l1

lB

l9

""
21

22

23

24

25

26

enhanced recruitment efforts or other outreach techniques, and other measures calculated either to attract and retain qualified staff, or to reduce the resident population, or both.
2. The number and categories of staff that will be utilized to implement plans required by paragraphs 3 through 11 below.
3. The procedures to be utilized to provide regUlar, periodic professional comprehensive evaluations/assessments of each resident in order ta identify individual needs for medical or psychiatric treatment.
4. The procedures to provide a sufficient number of treatment program hours to each resident for whom such treatment is necessary.
5. The procedures to be utilized to provide for increased consultation and communication of relevant information between and among personnel regarding residents' care, medical and psychiatric treatment needs, as well as the increased communication of such information to staff who provide residents with care or treatment.
6. Recordkeeping systems and administrative procedures, with respect to each resident's care, medical and psychiatric treatment, that shall be utilized to maintain and make readily available in each resident's record and elsewhere, as necessary, such information as is professionally necessary to permit the exercise of• professional

Page 12 -- Consent Decree
i '

1 -

judgment in that resident's care, medical and psychiatric

2

treatment.

3

7. The policies and procedures that will govern the

4

use of medications, including policies and procedures

5

concerning the handling and storage of medications, moni-

6

toring and review of whether the medications prescribed for

7

and administered to each resident are appropriate for the

8

needs of that resident, monitoring of residents for drug

9

side effects, evaluation of drug dosage levels, and the

w

review of the use of two or more drugs in combination,

ll

telephone orders and PRN prescriptions.

8. The policies and procedures that will be utilized

u

to ensure that bodily restraints and seclusion are (1)

M

administered only pursuant to the judgment of qualified

2

professionals; and (2) not used as punishment, in lieu of

treatment programs prescribed by a qualified professional,

or for the convenience of staff. It is understood by the

parties that restraint and seclusion may be used, when

appropriate, to control residents when they engage in

isolated incidents of violence and/or dangerous behavior.

Said policies and procedures shall provide that the decision

to place a resident in restraints or seclusion shall be

recorded promptly in the resident's records and shall be

reviewed by a qualified professional at specified reasonable

intervals to determine whether or not continued restraint or

seclusion is professionally justified.

Page 13 -- Consent Decree

i
!
l 2 3 4 5 6 7

9. The policies and procedures that will be utilized to ensure that residents will be protected from unreasonable risks of bodily harm to their personal safety by the conduct of staff or other residents, including requirements for staff to report incidents of bodily harm or allegations of such harm. Said policies and procedures shall include requirements for investigation of such incidents or allega-

8

tions, and sanctions to be imposed on staff found to have

•

caused or been responsible for causing harm to any resi-

l.O

dent, as well as procedures to ensure adequate staff

ll

supervision of residents and security measures designed

l2

to protect residents from unreasonable risks of bodily

l3

harm.

l.4

10. The enforcement mechanisms to be used, including

lS

disciplinary measures and sanctions where appropriate,

l8

to ensure staff compliance with all policies, rules and

standards of job performance and behavior which are related

18

to resident care and treatment.

19

11. Training and continuing in-service training pro-

20

grarn(s) that will be provided to enable all staff to fully

2l

implement the requirements of this Consent Decree.

22

B. Each plan shall: (1) set forth in specific terms and

23

reasonable detail the actions to be taken by the State, including

24

ithe dates for such actions; (2) include the full text of the

25

!procedures, regulations and protocols promulgated and issued by

26

;the State in the course of implementing the plan and Decree, or

Page 14 -- Consent Decree
I
i

,,
I
;.!~'

1

utilized or adopted by NSH to fulfill its obligations under the

2

l'' ,plan and Decree; and (3) identify the name and qualifications of
I,

3

!'the professional consistent with whose professional judgment the

!

4

!plan has been prepared and subnitted.

5

C. Each plan shall state a specific date or dates by which

6

,the plan shall be implenented in toto, but in no event shall the

7

final implementation date of any plan required in paragraph A.l

8

of Part V be later than three years fron the date of entry of

g

this Consent Decree by the Court, and, with respect to all other

lJ)

. plans required by Part V, two years from the date of entry of

ll

this Decree by the Court.

12

'VI. CONSTRUCTION AND IMPLEMENTATION

l3

In construing and implementing the terms of this consent

i

14

Decree, the following are agreed to by the parties:

A. Defendants shall file the plan(s) required by Section V

l6

with the Court and the United States within 90 days of the entry

J:7

;of this Consent Decree. The United States shall have 60 days

JS

1from receipt of any plan in which to file a response to the plan

19

with the Court. If the United States objects to any plan or

""

I portion thereof filed by the State, the parties shall confer

21

in a good faith effort to resolve their differences. If the

22

parties are unable to resolve their differences through

23

negotiation, the adequacy of the contested portions of the

24

'proposed plan shall be determined by the Court. Defendants

25

shall have the burden to persuade the Court that the plan is

26

adequate.

Page 15 -- Consent Decree

i
'I
I '
1

B. If, after a plan is approved~ State officials decide to

2

modify that plan or any portion thereof, State officials shall

3

,notify the Court and the United States of the proposed modifi-

4

cation. The United States shall have 60 days from the receipt

5

:of any proposed modification in which to file a response to the

6

,iproposed modification with the Court. If the United States

7

objects to the modification sought, the parties shall confer in

8

a good faith effort to resolve their differences concerning the

•

!proposed modification. If the parties are unable to resolve

lD

:their differences through negotiation, the adequacy of the

ll

:proposed modification shall be determined by the Court.

l2

Defendants shall have the burden to persuade the Court that

I

I

J3

1the modified plan is adequate.

l4

c. Plans submitted to the Court, including modifications of

15

plans, to which the United States does not timely object, shall

,..

;'be d"eemed approved by the Court.

l:]

D. All plans submitted under Part V of this Consent Decree,

lS

!if approved by the Court, shall be issued as orders of the Court

J9

;: and shall be enforceable as such.

20

E. Defendants shall submit quarterly compliance reports

2l.

'to the United states and the Court regarding the status of the

i .

22

State's compliance with the requirements of this consent Decree.

23

These compliance reports will commence for the three-month period

24

'. beginning _______ , 1990, and will be submitted to the United

25

States and the Court within 15 days of the end of each period.

26

Page 16 -- Consent Decree

1

These quarterly reports shall continue until the parties agree

2

otherwise or until dismissal of this action.

3

F. Each compliance report shall specifically describe the

4

,actions the State has taken during the reporting period to comply

5

!with each provision of Parts III and IV of this Decree and each

6

1 plan submitted pursuant to Part V of this Decree, For the last

7

full month of each reporting period, the compliance reports shall

8

'also include the following information:

•

1. The average daily resident population and any

lD

projected resident population figures;

ll

2. The number of residents with acute and continuing

l2

care needs;

13

3. An analysis which translates the ratios set forth

lA

in Part IV of this Consent Decree into numbers of staff for

15

each employee category specified in Part IV.

16

4. The number of staff in each employee category

J:7

specified in Part IV of this Consent Decree who are actu-

lS

ally in a full-time or part-time employment status at NSH.

19

G. Each compliance report shall specifically describe the

""

steps the State has taken during the preceding 120 days to meet

21

the required staffing ratios specified in Part IV.

22

H. The State agrees to provide to the United States, within

23

30 days of their receipt, written responses to written questions

24

from the United States regarding information provided in the

25

compliance reports or other matters that relate to the State's

26

:compliance with the provisions of this Decree·.

Page 17 -- Consent Decree

:I :I

1

I. The United States and its attorneys, consultants and

2

agents shall have reasonable access to the facilities, records,

3

residents and employees of NSH upon reasonable notice to the

4

,State for the purpose of ascertaining compliance with this

s

Consent Decree. Such access shall continue until this Consent

6

Decree is terminated.

7

J. All parties shall bear their own costs, including

8

attorney fees.

•

VII. TERMINATION OF DECREE

JD

A. The parties contemplate that the State shall have fully

11

', and faithfully implemented all provisions of this Consent Decree,

12

ialong with all plans herein required to be submitted to and ap-

i

l3

!proved by the Court, and will achieve the purposes and objectives

I '

lA

of Part II of this Decree, on or before three years from the date

15

_; of entry of this Decree by the Court.

15
l

B. The Court shall retain jurisdiction of this action for

17

i all
'

purposes

under

this

Consent

Decree

until

the

State

shall

have

l8

fully and faithfully implemented all provisions, purposes and

l9

objectives of the Consent Decree, along with plans submitted

20

pursuant thereto, and until the judgment is discharged.

21

C. On or after the date on which defendants shall have

22

fully and faithfully implemented all provisions of this Consent

!

23

1Decree and plans submitted thereto, defendants may move that the

24

injunctions entered herein be dissolved, the judgment discharged,

25

jurisdiction terminated, and the case closed and dismissed with

26

prejudice on grounds that defendants have fully and faithfully

Page 18 -- Consent Decree

I

--

1-

implemented and maintained all provisions of the Consent Decree

2

and plans submitted pursuant thereto.

3

o. Dismissal shall be granted unless, within 60 days after

4

receipt of defendants' motion, the United States objects to the

s

, motion. If such an objection is made with particularity, the

6

Court shall hold a hearing on the motion and the burden shall be

7

on the United States to demonstrate that defendants have not

8

fully and faithfully implemented all provisions of the Consent

9

Decree or any approved plan(s) or any part thereof and, if

JD

objection is based upon failure to implement any plan or part

ll

thereof, that such plan or part thereof is essential to the

l2

achievement of one or more of the purposes and objectives in

l3

Part II of this Consent Decree. If the United States fails

lA

to meet this burden, the injunctions shall be dissolved, the

lS

judgment shall be discharged, jurisdiction shall be terminated

16

forthwith, and the case shall be closed and dismissed with

X7

prejudice.

JS

CONSENTED TO BY THE UNDERSIGNED:

l9

FOR THE STATE OF CALIFORNIA

FOR THE UNITED STATES OF AMERICA

,,,,

21

22

. JOH ·' A. tta

ney

DE KAMP General

Stat of California

23

24 Q-~~~=

25

I LPtt: JOHNSON

,Deputy Attorney General

26

State of California

R. DUNNE A istant Attorney General
civil Rights Dision
1
~. J _ . / ' ~
~I . T. MCGIVERN
UnitdStates Attorney Northern District of California

Page 19 -- Consent Decree

I

I

i,

I
I'

I

1

I

2 3 4

f l ~ !Ir ~\/Yl 61}

: -:::,

:11 LYNWHETSTONE
Acting Director

l d w J v - ~ ARTHUR E. PEABODY,JR.
Chief

5

IDepartment of Mental Health

Special Litigation Section

I

6

'

7

P, FRIDAY

8

Executive Director

Napa state Hospital

9

10

11

l2

13

14

Deputy Chief Special Litigation Section
#tt1wl tf.1--1",t~ EDWARD A, STUTMAN ROBERT H, STERN Attorneys Special Litigation Section Civil Rights Division U.S. Department of Justice Washington, D.c.

l5

16

WHEREFORE, the parties to this action having agreed to the

X7

,,provisions in the consent Decree set forth above, and the Court

lS

being advised in the premises, the Court finds that the consent

l9

Decree is a reasonable, lawful and fundamentally fair resolution

,.,

of this case and hereby enters the consent Decree as the JUDGMENT

21

I 11of

the

Court.

22

! '

IT rs so ORDERED, this {? day of

',/1990,

23

at San Francisco, California.

24

2S
ISTRICT JUDGE
26

Page 20 -- Consent Decree

 </s> Memorandum

U.S. v. Cal.

WBR:AEP:BPS:RAS:dw DJ 168-017-11

MR-CA-005-00-

Subject

Date

Napa State Hospital Proposed S.lO Investigation

To

From

Wm. Bradford Reynolds Assistant Attorney General Civil Rights Division

Arthur E. Peabody, Jr.
Chief
Special Litigation Section

We recommend the initiation of an investigation into conditions of confinement and treatment at Napa State Hospital (NSH), pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. §1997. NSH is a state facility located in Imola, California. It is operated by the Department of Developmental Services. NSH was established in 1875 and is presently certified by the Department of Health and Human Services (HHS) for 1943 beds. 1/

Sources of Information

A lawsuit on behalf of four patients at NSH concerning the conditions of confinement first brought our attention to this facility. 2/ Many of the factual allegations were derived

1/ Telecon. Ronald Curry May 17, 1985. The reported number of "Beds varies from 1600 (See San Francisco Chronicle, April 5, 1984) to 1835, see JCAH Survey Report (JCAH Survey), October 19, 1984, p. 6.
2/ Dennis Bedger, David Hendrickson, by and through his conservator Barbara Teyrel, Gary Wolpert, by and through his conservator^ Fred Wolpert, Kristine Hamala, by and through her conservator, Marge Hamala v. Napa State Hospital, Michael O'Connor, individually and in his capacity as Director of the Department of Mental Health for the State of California, Gary MaComber, individually and in his capacity as Director of the Department of Developmental Services for the State of California, Fred Valenzuela, individually and in his capacity as Executive Director of Napa State Hospital, et. al., Civil Action No. C85-0983, U.S. District Court, Northern District of California, filed January 23, 1985. This is not a class action suit, thus any remedy achieved would be limited to the four patients named in the suit.

-2-
from two surveys of NSH conducted by the Joint Commission on Accreditation of Hospitals (JCAH). The first was conducted in October of 1983 and the second in August 1984. Although presently on a second appeal, JCAH officials decided not to accredit the facility. 3J Other sources of information include the following: newspaper articles; Families and Advocates for the Mentally 111 of Napa State Hospital; letters and conversations with patients and their parents; and a memo of County Liaisons concerning the conditions of confinement.
Personal Safety
Based on our information, a pattern of violence prevails at NSH. Frequent deaths have occurred at NSH over the past year and a half, four of them since the beginning of 1985. These include patient suicides and murders as well as the death of a staff member. In light of NSH policy to hold all incident reports confidential from the general public in addition to liaisons and conservators of patients involved , 4_/ the disturbing number of incidents that we have documented takes even greater significance.
On April 27, 1985, Marilyn Marie Conners failed to return to her ward after she and another patient were permitted out on the grounds of NSH under a "buddy pass" system. While on the grounds, the two separated and Marilyn was observed going off with a man. Her nude body was found on April 29, 1985, about 200 yards from the fenced hospital grounds. An autopsy revealed she was strangled to death sometime on the 27th. The police suspect another patient, with a history of aggressive, assaultive behavior, of Ms. Conners' murder. 5/
At approximately 4:30 p.m. on March 3, 1985, Sandra Wilson went to her room at NSH because she did not feel well. For an hour and a half Ms. Wilson was not seen and no staff member checked on her condition. At 6:00 p.m., after a head count by staff, Ms. Wilson was discovered dead in her room. It has been determined that she was strangled by a male patient. 6_/
3/ Napa Register, March 27, 1985.
4/ Memo of County Liaisons at Napa State Hospital to Greater Bay Area Conference of Local Mental Health Directors (Memo of County Liaisons), undated but reportedly completed in the latter part of 1984, p. 2; Telecon. Barbara Teyerl, March 5, 1985.
5/ Napa Register, May 1, 1985.
6/ Letter of Helen Gerling, President of Families and Advocates Tor the Mentally 111 of Napa State Hospital, March 12, 1985; Napa Register, March 4, 1985.

-3-
Another incident involved Tina Gonzalez, who was placed in solitary confinement for aggressive behavior. When staff checked on her condition they found Ms. Gonzalez strangled to death by a bedsheet. Hospital officials have labeled this a suicide. ]_/ However, this death brings into question the adequacy of supervision and use of seclusion procedures by NSH staff.
In March of 1985, another patient committed suicide by setting herself on fire. 8/ Similarly, on January 6, 1984, a female patient was given a "grounds pass" by NSH staff. She wandered off the hospital grounds to a nearby gasoline station where she committed suicide by setting herself on fire in the gas station's bathroom. 9_/ Finally, a patient with documented suicidal tendencies was placed in unsupervised seclusion where he again attempted suicide, sustaining third degree burns on his arms. 10/
In addition to the murders and suicides at NSH, assaults are common occurrences. It is reported that there are more than 5000 violent attacks each year on patients and hospital workers. _11/ One patient characterized the environment at NSH as "hostile." YLJ A patient was so severely beaten at the facility that he sustained permanent brain damage. _13_/ On September 20, 1984, Al Gonzalez, a staff member, intervened in a fight between two patients and was killed. One patient is now awaiting trial for Mr. Gonzalez's murder. It was reported that these patients were fighting previously, but were not separated by staff members. 14/
In December of 1984 a patient was attacked by another patient who thought he was poisoning the food. This fight was halted by other patients; no staff member intervened. In January 1985, this same patient intervened on behalf of a
]_/ Letter of Helen Gerling, March 12, 1985; Napa Register, December 29, 1984.
87 Telecon. Barbara Teyerl, April 29, 1985.
£/ Napa Register, January 12, 1985; Telecon. Helen Gerling June 7, 1985.
10/ Letter of Lois Eneshenko to Helen Gerling, November 16, 1984.
11/ San Francisco Chronicle, April 5, 1984.
12/ Telecon. Dennis Bedger, March 15, 1985.
13/ Letter of Lois Eneshenko to Helen Gerling, November 16, 1984.
14/ Napa Register, October 22, 1984; October 30, 1984; November 5, T984.

-4-
staff member involved in a fight with a fellow patient. As a result, the patient was badly beaten. 15/ Finally, the parent of one patient found bruise marlcs on her son1 s neck due to assaults by a staff member. That staff member is still employed at NSH while undergoing psychiatric treatment. 16/
Furthermore, our information shows that drugs are available on the grounds of NSH, even in the wards themselves. 17/ This exacerbates the already dangerous environment to wKich a vulnerable population is exposed. There are eyewitness accounts of patients and high school students selling prohibited items, including drugs, on the grounds of NSH. _18_/ Some patients have been caught by staff members smoking marijuana. 19/
We believe that the existing pattern of violence over this short period of time is due to a combination of insufficient staffing, inadequate supervision of staff and the lack of a classification system. The loss of 191 staff members over a ten month period was "significant" to JCAH surveyors, who noted staff deficiencies for nurses, social workers and psychiatric technicians (i.e., direct care staff). Surveyors also determined that supervision of staff was provided by individuals lacking credentials or experience necessary to supervise, i.e., psychiatric technicians. In addition, psychiatric technicians and other non-physician staff were found to have overall responsibility for the quality of clinical care provided to patients and to have evaluated physicians' professional competence. 20.1 Staff development was determined to be limited and failed to increase professional competence. 21/
15/ Telecon. Dennis Bedger, March 15, 1984.
16/ Telecon. Barbara Teyrel, May 5, 1985.
17/ Memo of County Liaisons, pp. 4-5.
18/ Id.; Letter of Lois Eneshenko to Helen Gerling, November 16,
T9847"
19/ Statement of Anthony Hoffman, June 16, 1984.
20/ JCAH Survey, pp. 3 and 6.
21/ JCAH Survey, p. 10.

-5-
Approximately 30% of NSH1s population are aggressive, assaultive and manipulative patients who are housed indiscriminately with the general population. 22.1 JCAH discovered
patients placed in large dorms regardless of their age or
clinical needs. ^3./ I c w a s reported by the County Liaisons that 21 out of 25 adult wards have an inappropriate mix of patients. 2k_l There are 250 penal code (i.e., forensic) patients in the facility, 25/ a number of whom JCAH surveyors found on every ward . 26_/ ThTs lack of segregation endangers vulnerable patients by making them easy prey for those more aggressive, assaultive and manipulative patients housed in the same wards, and therefore more susceptible to unreasonable risks to their personal safety.
Fire Safety
There is also a serious threat to the life and health of residents at NSH from inadequate fire prevention and safety measures. JCAH surveyors found numerous deficiencies at the facility which pose a present danger of residents being trapped and consumed by fire. Deficiencies were found in all buildings of NSH and include the following:
1. All but one building lacked a fire alarm system; 2. Several exits were obstructed by closed courtyards; 3. Lack of 1-hour fire-resistive construction or approved
automatic fire extinguisher system in "hazardous" areas; 4. Failure to provide two approved remote exits on each
floor or fire section of the building; 5. Large open wards in which patients' doors do not open
directly onto exit corridors; 6. Failure to provide illuminated exit signs; and 7. Louvers and transoms in corridor doors were not closed
and made smoke tight by permanent noncombustible construction. 27/
22/ Memo of County Liaisons, pp. 1, 6-8; Napa Register, November 2, T984.
23/ JCAH Survey, p. 17.
24/ Memo of County Liaisons, p. 1.
25/ Napa Register, May 1, 1985. This is the maximum amount allowed under state legislation.
26/ Summation conference between the Survey Team of the JCAH and tfEe Employees of Napa State Hospital (JCAH Summation Conference) , November 18, 1983, p. 3.
27/ JCAH Survey, pp. 12-15.

-6-
Additionally, there is a grave question of whether present staff Levels would b e sufficient to safely escort the patients out o f the facility in time of an emergency. 28/
Medical Care
Harm has also come to the patients at NSH through inadequate medical care. JCAH reported that the medical staff isgiven little authority and minimal opportunity to effectively influence decisions a b o u t m e d i c a l c a r e . _29_/ O n the night shift JCAH found i n s u f f i c i e n t and unqualified medical staff. This was determined tob e a "serious hazard to patient h e a l t h and safety." 3_0/ Only one physician was available on the night shift for the entire 1835 bed facility. On numerous occasions JCAH ascertained that the one physician on the night shift was a psychiatrist who was not experienced or trained in general medicine or surgery. 31/
The medical care provided to patients itself has serious deficiencies. Patients' medical problems are ignored, misdiagnosed and improperly treated. In the Summer of 1984, Mr. Dennis Bedger, a patient at NSH, pleaded for medical attention when h e began to suffer from a bladder and urinary tract infection. When Mr. Bedger was eventually transported to the hospital h e had to have his right testicle surgically removed due to the severe infection. He spent three months in the hospital recovering. When h e returned to NSH h e developed another urinary tract infection that was again ignored by NSH staff. When Mr. Bedger was finally treated bya urologist, a visicostomy had to b e performed. As a result, h e is forced to wear a plastic bag to collect his urine. After Mr. Bedger returned to NSH a third urinary tract infection developed which was again ignored by NSH staff until the infection was so severe that he had to b e treated b y intravenous antibiotics. 3 2 /
Barbara Robinson was transferred to a medical-surgery ward of NSH on March 18, 1985. She was told she had pneumonia and a fever. Two days after the transfer, Ms. Robinson's mother was
28/ This concern ishightened b y overcrowding and poor lighting conditions found by JCAH surveyors. See JCAH Survey, p . 1 6 .
29/ JCAH Survey, p . 3.
30./ I_d. at 1 9 .
n / Id.at 6, 18-19.
32/ Bedger v. Napa State Hospital, Civil Action No. C85-09853.

-7-
told that her daughter might have tuberculosis and therefore could not visit her. Some ten days later Ms. Robinson was transferred to a local hospital with a 104-105 degree fever. She died four days later. 33/
Gary Wolpert developed tardive dyskinesia allegedly due to the overuse of medication. ^34/ Another patient attempted suicide allegedly as a result of the inappropriate mixture of thorazine and other neuroleptics. 3jj/ Kristine Hamala, a patient at N S H , had diseases of the teeth and gum that were allegedly ignored by staff personnel. 36/
Medical records were also criticized by JCAH surveyors. They concluded that treatment plans failed to identify the clinical needs of the patients and lacked documented goals, objectives (in measurable terms) and criteria for the termination of treatment. _3_7_/ These recordkeeping deficiencies indicate that patients' medical records are inadequate to serve as a basis for medically appropriate and reasonably safe treatment decisions.
Freedom From Unncessary Physical Restraint
Our information shows that the use of restraint and seclusion at NSH violates patients' constitutional rights. The lack of clinical assessment, specific treatment plans, and proper documentation and supervision has led to widespread abuse of seclusion and restraint.
After a violent reaction to psychotropic medications, David Hendrickson was put in 4 and 5 point restraints for more than one year. While in seclusion he was given no clothes, sheets or blankets and NSH staff continued to administer psychotropic medication despite David's documented paradoxical response. 38/ In another case, a patient
33/ Letter of Helen Gerling, May 2, 1985; Telecon. Mrs. Robinson, May 17, 1985.
34/ Bedger v. Napa State Hospital, Civil Action No. C85-09853.
35/ Letter of Louis Eneshenko to Helen Gerling, November 16, 1984.
36./ Bedger v . Napa State Hospital, Civil Action N o . C85-09853.
37/ JCAH Survey, pp. 10-11.
38/ Bedger v. Napa State Hospital, Civil Action No. C85-09853; Letter of Barbara Teyrel to JCAH, August 2 8 , 1984.

was put into seclusion for agitated behavior and until, according to staff, "he tells us why he acted that way." 39/ Another patient had a scuffle with a psychiatric technician after the patient refused to clean the ward floors at night. For this he was placed in five point restraints for three hours without any clothes. 4J)/ These are clearly inappropriate uses of seclusion and restraint.
JCAH surveyors found occasions when "special treatment procedures" (restraint and seclusion) were employed for staff convenience or for punishment. The rationale for use of these "special treatments" was not documented and their use represents a substantial departure from the exercise of professional judgment. In addition, JCAH discovered PRN (pro re nata, "as needed") orders used "extensively" in treatment plans. Clinical assessments were found to be cursory, infrequently done prior to writing an order for seclusion or restraint and were conducted over the telephone after the fact. Although review of seclusion and restraint orders is to be done by the head of the professional staff, it was frequently conducted by a secretary, who then reported the numbers to the clinical director. 41/
Conclusion
Based on available information, we believe an investigation of NSH is warranted in order to determine whether NSH is depriving residents1 of their constitutional rights. These rights may be violated due to the existing pattern of violence against patients; inadequate fire safety and prevention measures; overuse and misuse of seclusion and restraint; inadequate medical care; and inadequate treatment and programming as is necessary to further the residents' interest in safety and freedom from undue bodily restraint. The need for our investigation is especially great in light of the recent deaths at NSH over a short period of time.
Notice letters as required by CRIPA are attached for your review and signature.
U&fc Approved:
Disapproved:
Comments:
39/ Letter of Stephen and Nona Kaufman to Helen Gerling, January 15, 1985, quoting NSH staff member.
40/ Letter of Helen Gerling, April 29, 1985.
41/ JCAH Survey, pp. 11-12.

 </s> U.S. v. Cal.

U.S. Department o. Justice Civil Rights Division

• v> • • • • • • • • i
MR-CA-005-002

Office of the Assistant Attorney Central

Washinxton. DC. 20530

Honorable Margaret Heckler Secretary United States Department;
of Health and Hunan Services 200 Maryland Avenue, S.W. Washington, D.C. 20201

17 JUL 19B5

Re: Investigation of Napa State Hospital Imola, California

Dear Secretary Heckler-.

I wish to advise you, pursuant to tne Civil Rights of Institutionalized Persons Act, 42 U.S.C. §1997h, of our intent to investigate Napa State Hospital, Iraola, California.

We have received allegations that the institution may be violating the constitutional and statutory rights of institutionalized persons with respect to misuse of seclusion and restraints; inadequate medical care; abuse, neglect and patient safety; and inadequate training as is necessary to further the residents' Interests in safety and freedom from restraint. Please inform us of the nature and extent of all federal financial assistance which your Department provides to this institution or to a related agency. Please be advised that during the course of this investigation we will suggest that state officials contact appropriate officials at your Department to discuss and explore whatever financial or other assistance may be available to remediate any constitutional deficiencies which may be ascertained.

We will cooperate fully with your Department in this matter and will consult with you regarding the status of our investigation. The attorney assigned to handle this matter is Robert A. Spelke, (202) 272-6076.

Sincerely,

Win. "Bradford Reynolds Assistant Attorney General
Civil Rights Divisions
cc: Isabel Dunst, Esquire Assistant General Counsel

U.S. Department u. Justice Civil Rights Division

Office of the Assistant Attorney General

Washington. DC 20530

Honorable William Bennett Secretary United States Department
of Education 400 Maryland Avenue, S.W. Washington, D.C. 20202

1 7 J UL £i>5

Re: Investigation of Napa State Hospital Itnola, California

Dear Secretary Bennett:

I wish to advise you, pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. §1997h, of our intent to investigate Napa State Hospital, Imola, California.

We have received allegations that the institution may be violating the constitutional and statutory rights of institutionalized persons with respect to misuse of seclusion and restraints; inadequate medical care; abuse, neglect and patient safety; and inadequate training as is necessary to further the residents' interests in safety and freedom from restraint. Please inform us of the nature and extent of all federal financial assistance which your Department provides to this institution or to a related agency. Please be advised that during the course of this investigation we will suggest that state officials contact appropriate officials at your Department to discuss and explore whatever financial or other assistance may be available to remediate any constitutional deficiencies which may be ascertained.

We will cooperate fully with your Department in this matter and will consult with you regarding the status of our investigation. The attorney assigned to handle this matter is Robert A. Spelke, (202) 272-6076.
Sincerely,

Wra. Bradford Reynoras
Assistant Attorney General Civil Rights Divisions
cc: Maureen Corcoran, Esquire Assistant General Counsel

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 </s> U.S. District Court Web PACER(v2.3) Docket Report

Page 1 of 4

Docket as of August 12, 1995 0:53 am

Web PACER (v2.3)

U.S. District Court
U.S. District for the Northern District of California (S.F.)
CIVIL DOCKET FOR CASE #: 90-CV-2641
USA v. State of CA, et al
Filed: 09/13/90 Assigned to: Judge Eugene F. Lynch
Demand: $0,000 Nature of Suit: 440 Lead Docket: None Jurisdiction: US Plaintiff Dkt# in other court: None Cause: 42:1983 Civil Rights Act

UNITED STATES OF AMERICA Plaintiff
v.
CALIFORNIA, STATE OF defendant
CALIFORNIA DEPT. OF MENTAL HEALTH
defendant
LYNN WHETSTONE, Acting Director California Department Of Mental Health
defendant
RICHARD FRIDAY, Executive Director Napa State Hospital
defendant
GEORGE DEUKMEJIAN, Governor of State of CA
defendant

John R. Dunne (202) 514-1641 [COR LD NTC] USDJ-Housing & Civil Enforcement Civil Rights Division P O Box 65998 Washington, DC 20035-5998

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U.S. District Court Web PACER(v2.3) Docket Report

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DOCKET PROCEEDINGS

DATE #

DOCKET ENTRY

2/28/90 8 9/13/90 1 9/13/90 2
9/13/90 3 9/13/90 -9/17/90 4 10/1/90 5 11/19/90 6
12/28/90 7 12/28/90 9 12/31/90 10
12/31/90 11
3/1/91 12

DECLARATION by defendants re State Plan of Implementation Vol. 3 of 3 (db) [Entry date 01/07/91]
COMPLAINT (Summons(es) issued) (db) [Entry date 09/14/90]
ORDER by Judge Eugene F. Lynch setting status conference for 8:45 12/19/90 (cc: all counsel) (db) [Entry date 09/14/90]
REQUEST to substitute parties; by plaintiff USA for (db) [Entry date 09/14/90]
RECEIVED proposed consent decree by plaintiff US (db) [Entry date 09/14/90]
ORDER by Judge Eugene F. Lynch dismissing case by CONSENT DECREE (cc: all counsel) (db) [Entry date 09/21/90]
NOTICE of approval & entry of consent decree; by defendant (db) [Entry date 10/04/90]
STIPULATION and ORDER by Judge Eugene F. Lynch : ; Case Mgmt ddl 12/31/90 complete review required by Part 111A of Consent Decree (cc: all counsel) (db) [Entry date 11/27/90]
DECLARATION by defendants re state plan of implementation Vol. 1 of 3 (db) [Entry date 01/07/91]
DECLARATION by defendants of State plan of implementation vol. 2 of 3 (db) [Entry date 01/07/91]
STATEMENT of facts, Quarterly compliance rreport for the quarter ending 12/17/90 by defendant (db) [Entry date 01/07/91]
RETURN OF SERVICE of Response to terms of t;he Consent Decree, Corrective Action Plan et al executed 12/28/90 (db) [Entry date 01/07/91]
RESPONSE by plaintiff USA to proposed plans of implementation (db)

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U.S. District Court Web PACER(v2.3) Docket Report

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3/4/91 13
3/4/91 14 4/11/91 15
7/12/91 16 8/30/91 17
10/22/91 18 1/21/92 19 5/4/92 20 7/21/92 21 10/30/92 23 2/8/93 22 7/21/93 24 3/24/94 25 3/24/94 26 12/13/94 -12/13/94 27

STIPULATION and ORDER by Judge Eugene F. Lynch : ; Motion filing ddl 4/15/91 defendants file quarterly report to cover 12/17/90 through 3/31/91 and shall conform to the Consent Decree. ) (db) [Entry date 03/05/91]
DECLARATION by Scott Erlewine on behalf of defendants in support of motion to dismiss amended complaint. (db) [Entry date 03/05/91]
DECLARATION of Quarterly Compliance Report for the Quarter ending 3/31/90 by Ralph Johnson on behalf of defendant (db) [Entry date 04/16/91]
Quarterly compliance report for rthe Quarter Ending 6/30/91 DECLARATION by Ca. Attorney General on behalf of defendant State of CA (db) [Entry date 07/15/91]
STIPULATION and ORDER Defendants plans of implementation, filed 12/28/90 as modified by the stipulation set forth, entered as an order of court by Judge Eugene F. Lynch : (cc: all counsel) (db) [Entry date 09/05/91]
NOTICE by defendants of Quarterly Compliance Report for the Quarter ending September 30, 1991 (seal)
NOTICE of Quarterly Compliance Report for the Quarter ending 12/31/91 by defendant (db)
NOTICE of quarterly compliance report for the quarter ending 3/31/92 by defendant (th) [Entry date 05/05/92]
STATEMENT of facts by defendants re quarterly compliance report for the quarter ending June 30, l992 (db) [Entry date 07/22/92]
NOTICE by defendants of Quarterly Compliance Report for the quarter ending 9/30/92 (db) [Entry date 03/30/93]
NOTICE of Quarterly Compliance Report for the Quarter ending 12/31/92 by defendants (db)
NOTICE of quarterly compliance report for the quarter ending 3/31/93 by defendants (db)
NOTICE of quarterly compliance report for the Quarter ending 9/30/93 by defendants [3:90-cv-02641] (db) [Entry date 03/25/94]
NOTICE of quarterly compliance report for the quarter ending 6/30/93` by defendants [3:90-cv-02641] (db) [Entry date 03/25/94]
RECEIVED Letter dated 12/13/94 by Ralph Johnson with enclosed stipulation [3:90-cv-02641] (mcl)
STIPULATION and ORDER by Judge Eugene F. Lynch : re Consent Decree on 9/17/90 and modified stipulation on

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U.S. District Court Web PACER(v2.3) Docket Report

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4/17/95 28 6/2/95 29 6/2/95 30 6/2/95 31 6/8/95 32 6/8/95 33

8/30/91, ... within 120 days of approval of this stipulation, defendants shall submit to the Court a report (see order) (cc: all counsel) [3:90-cv-02641] (mcl) [Entry date 12/14/94]
SEPCIAL REPORT on compliance status re 12/13/94 stipulation by defendant [3:90-cv-02641] (mcl) [Entry date 04/20/95]
MOTION before Judge Eugene F. Lynch by State defendants to terminate consent decree [3:90-cv-02641] (mcl)
[Entry date 06/05/95]
MEMORANDUM by defendants in support of motion to terminate consent decree [29-1] [3:90-cv-02641] (mcl) [Entry date 06/05/95]
STATEMENT of non-opposition by Plaintiff USA [3:90-cv-02641] (mcl) [Entry date 06/05/95]
LETTER dated 6/1/95 from Ralph M. Johnson re enclosed proposed Order [3:90-cv-02641] (mcl) [Entry date 06/09/95]
ORDER by Judge Eugene F. Lynch defendants having fully implemented the requirements of the Consent Decree, dismissing case with prejudice ( Date Entered: 6/9/95) (cc: all counsel) [3:90-cv-02641] (mcl) [Entry date 06/09/95]

Case Flags: TERMED CSMDDL

END OF DOCKET: 3:90cv2641

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[CONTENT] January 23, 1985 | four | the Napa State Hospital | Napa Valley | California | the Department of Mental Health for the State of California | the U.S. District Court | the Northern District | California ||| the U.S. Department of Justice | June 25, 1985 | 42 | U.S.C. &sect | 1997 | the Civil Rights of Institutionalized Persons Act ||| September | 13, 1990 | the Department of Justice | 42 | U.S.C. &sect | 1983 | the State of California | District Court | the Northern District | California ||| DOJ | NSH ||| September 17, 1990 | the U.S. District Court | the Northern District | California | Eugene F. Lynch |||  ||| June 2, 1995 ||| June 8, 1995 | Lynch [SUMMARY] On January 23, 1985, four patients at the Napa State Hospital (NSH) in Napa Valley, California filed a lawsuit against the hospital and the Department of Mental Health for the State of California (DMH) in the U.S. District Court for the Northern District of California, alleging that their constitutional rights had been violated by conditions at the hospital.  This lawsuit drew the attention of the U.S. Department of Justice, who initiated an investigation into the conditions at the hospital on June 25, 1985, pursuant to 42 U.S.C. &sect; 1997, the Civil Rights of Institutionalized Persons Act (CRIPA).

On September, 13, 1990, the Department of Justice (DOJ) filed a lawsuit under 42 U.S.C. &sect; 1983 against the State of California in the U.S. District Court for the Northern District of California.  The DOJ alleged that the defendants had violated the constitutional rights of NSH patients by failing to provide adequate medical and psychiatric care, inadequate staffing levels and staff training, inadequate status review for patients, inadequate record-keeping, inadequate procedures for administration of medicine, and misuse of bodily restraints.

On September 17, 1990, the U.S. District Court for the Northern District of California (Judge Eugene F. Lynch) issued a consent decree in the case.  We have no information on the content of this decree.  On June 2, 1995, the defendants asked the court to find them compliant with the court's orders and terminate the consent decree.  The plaintiffs did not object to this motion, and on June 8, 1995, the court (Judge Lynch) terminated the decree and dismissed the case with prejudice.  