CENTRAL STATE HOSPITAL — Angel Love Fuller came into the waiting room with fear in her eyes.

Fuller, 36, was frail and emaciated because of the eating disorder that landed her here in Building 96, the new admissions unit for civil patients at a Virginia mental hospital that previously had admitted few of them for crisis care.

It was her final night here after a two-week stay — first on a ward primarily for intellectually and developmentally disabled patients, many of them in wheelchairs, and then on a ward filled with what she described as “paranoid schizophrenics.”

“The whole ward is like a nightmare,” Fuller tearfully told Bill Rogers, a Henrico County man who employs her to help care for his elderly parents and has advocated for her during a traumatic ride through Virginia’s troubled mental health system.

“I’m terrified of being in this place,” she said. “They’re bringing in these violent people and I’m trapped in the ward with all of these people.”

Building 96 is ground zero for a statewide mental health crisis that began with the best intentions. Five years ago, the Virginia General Assembly adopted a law that requires state hospitals to provide the “bed of last resort” to involuntarily detained people who pose a danger to themselves or others, or who, like Fuller, cannot care for themselves.

The law was the primary response to “streeting,” in which people who met the criteria for involuntary detention were allowed to go untreated because beds in a psychiatric facility weren’t found quickly enough. It was already a problem when Gus Deeds, the 24-year-old son of Sen. Creigh Deeds, D-Bath, attacked his father and killed himself on Nov. 19, 2013, less than 13 hours after being released from emergency custody because of failure to find an appropriate place for his care.

Now, the legislature and Gov. Ralph Northam’s administration face an urgent struggle to reverse a trend that has allowed private psychiatric hospitals to shift a greater portion of patients under temporary detention orders — they still treat most of them — to state hospitals that don’t have enough staff to handle them safely.

Hospital staff are getting hurt more often and employees are demoralized, especially those in Building 96, an admissions unit where patients with complicated medical needs and those with violent tendencies are kept under the same roof.

“CSH is a MENTAL HOSPITAL, not a MEDICAL HOSPITAL, nor is it a JAIL, but these type of people are being housed there and therefore they are not getting the proper care that is needed,” a group of Central State employees wrote in an anonymous message to the Richmond Times-Dispatch in early May.

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Deeds, as chairman of a joint subcommittee studying the state mental health system, said, “What’s going on at Central State is symptomatic of what’s going on across the system.”

“We’re at the point we’re going to have a bad tragedy,” he said Thursday. “We’ve got these hospitals at a boiling point. We have to get something done.”

With state mental hospitals operating at 98% of their combined capacity as of Sept. 9, a statewide work group is struggling to find a solution to relieve the unintended consequences of the “bed of last resort” law, so that people such as Angel Fuller don’t end up in the most restrictive setting instead of the least.

Private hospital officials say any solution also has to consider the strain on their emergency departments and their capacity, as more people come for treatment in psychiatric crisis that could be compounded by drugs, alcohol and violent behavior.

“Nobody wants to put a patient in a hospital that can’t care for them,” said Dr. Jake O’Shea, chief medical officer at HCA Healthcare’s Capital Division and a member of the new state work group on temporary detention orders, or TDOs.

Richard Bonnie, director of the Institute of Law, Psychiatry and Public Policy at the University of Virginia, said new kinds of limited treatment facilities are needed “to take the load off of emergency departments, which from a clinical standpoint is the worst place a person in crisis can be.”

But Bonnie, who also serves on the work group, said Virginia policymakers cannot continue to put people with complex medical needs in state mental hospitals that aren’t able to address those needs.

“We ought to take the state hospitals off of the table,” he said. “They do not have the capacity to deal with patients like that.”

Daniel Herr, deputy commissioner of Behavioral Health and Developmental Services, was informed personally when Fuller came to Central State on July 19 from HCA Henrico Doctors’ Hospital on Parham Road because Henrico emergency screeners found her unable to care for herself.

Local mental health workers sought to find an appropriate facility to take Fuller. Eighteen facilities — including Virginia Commonwealth University Health System and six hospitals operated by HCA — twice had refused to admit her for psychiatric care after she had been stabilized at Henrico Doctors’ for dangerously low potassium levels stemming from anorexia nervosa.

“I can’t say someone with anorexia nervosa, with any medical complications, would have never come to a state hospital, but it would have been exceedingly rare,” said Herr, who is responsible for Virginia’s nine mental hospitals and four other behavioral health institutions.

HCA officials declined to discuss Fuller’s case or provide a consent form to allow them to share her medical information. But Henrico records show that HCA first said her weight was too low and its hospitals could not treat anorexia. The second time, the hospital system said her condition was both too acute and chronic.

Fuller’s psychiatric history is complex. She said she was raped at 8 and suffers from post-traumatic stress disorder. The clinical record says she was a drug addict and that her reliance on Suboxone to keep her off opioids prevented some hospitals from taking her.

According to medical records, she had numerous psychiatric hospitalizations in her native Winchester before coming to Richmond 2½ years ago for a fresh start.

Before the last-resort law, Henrico’s community services board and others in the Richmond region sent relatively few patients to Central State but relied primarily on private facilities, said Daniel Rigsby, director of clinical and prevention services at Henrico Area Mental Health & Developmental Services.

“If someone shows up in psychiatric crisis, we have to see them, we want to see them,” Rigsby said. “It’s the same at the state hospitals. Private hospitals have the option of choosing. It creates a tension in the system.”

But he defended the decision to send Fuller to Central State, where she subsequently was committed for care after a hearing at the hospital.

“She didn’t die, and she was at risk of dying,” Rigsby said. “The system worked in that regard. Did it work perfectly? Probably not. In terms of her being alive and getting treated, it did work.”

But Bonnie, at UVA, said sending psychiatric patients with medically complex conditions to state mental hospitals raises patient safety concerns that policymakers need to address.

“We have to be able to handle people safely when they are in crisis,” he said. “Putting people in state hospitals because of the last-resort law is simply wrong.”

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One day in late April, Central State staff jumped into vans on the sprawling and decrepit hospital campus near Petersburg to head off violence in Building 96, which had become the admissions unit for civil patients weeks earlier.

They responded to potential fights 29 times between 7 a.m. and 3 p.m., according to a clinical employee on one of the civil units who asked not to be identified publicly but whose identity and role have been verified by The Times-Dispatch. The newspaper is not identifying the employee to protect the person’s job.

“There are fights every day, patient to patient,” the employee said.

State officials questioned the accuracy of the employee’s account. The hospital does not officially track response calls made to prevent violence as it does more urgent emergency calls, but spokeswoman Meghan McGuire said, “Central State is unable to verify or even recall any shift or day when there were close to that number of response calls in Building 96.”

The hospital recorded three days in April with five emergency calls for backup staff for actual or potential violence in Building 96 and one day with four emergency calls.

Hospital staff acknowledged that “April was a challenging month for Building 96” because of a high number of civil TDO admissions that month, as well as the April 1 reorganization of three units for civil patients, McGuire said. State officials also acknowledged an increase in patient assaults on employees, who contend they lack adequate security in the admissions unit and support from hospital leadership.

In 2017, Central State recorded 12 patient assaults on employees. Last year, the number nearly tripled, to 33. This year, the hospital had recorded 39 patient assaults on staff in less than seven months.

Herr, the deputy commissioner for facilities, called staff injuries “a core concern if not close to the number one issue” at the hospital. “It’s hard not to see a direct connection” between injuries and the patient census, he said.

Injuries to civil patients — those not housed in the maximum-security forensic unit, which is reserved for individuals who commit violent crimes — rose from 33 in 2014, the year the last-resort law took effect, to a peak of 63 in 2017 before declining to 48 last year.

This year, Central State recorded 24 patient injuries through August, almost all of them in the five months since it reorganized the civil units and their staffs on April 1 in response to the flood of acutely ill patients admitted to the hospital.

State officials say the increase in patient injuries has not risen proportionately to admissions, which have exceeded 100 every month this year except January. Instead, the rate of injuries per admission “has remained constant or even decreased as the admissions have gone up,” McGuire said.

“This can be credited to factors such as hospital staff making critical adjustments to accommodate the increasing patient population,” she said.

Before the last-resort law, Herr said Central State routinely admitted 50 to 60 patients under temporary detention orders in a year. In the fiscal year that ended June 30, the hospital had admitted 758 patients under TDOs, a 25% increase from the previous year.

Since fiscal year 2015, the first under the new law, the number of TDOs issued annually across the state has been relatively constant at around 25,000. But TDO admissions to state hospitals have nearly tripled, while the proportion of TDO admissions to private hospitals has declined from 91% to 77% in the last fiscal year.

“The challenge we have, we have to emphasize to our private partners that this is a core need of the communities they serve,” said Secretary of Health and Human Services Daniel Carey, a former cardiologist and hospital administrator in Lynchburg.

HCA Virginia says it has admitted almost 2,000 people under TDOs at its hospitals in the first eight months of this year. It has experienced a 3% increase in overall behavioral health admissions, including voluntary patients that private hospitals treat almost exclusively. It operates 526 beds for behavioral health patients, including 16 in a new unit in Pulaski County.

“It is an incredibly complex scenario with many moving parts,” said O’Shea, the chief medical officer for HCA, “and we’re trying to find the solution that provides the most good for the most people.”

But the scenario that’s playing out at Central State is a reversal of its more than two-decade transition away from acute care for civil patients to treating forensic patients with varying levels of criminal charges and people who need long-term treatment for conditions that private providers can’t manage.

Previously, Central State relied on the maximum-security forensic unit to handle all admissions.

In April, Building 96 became the admissions unit for acutely ill patients. Ward 1 was reserved for up to 22 patients with medical conditions and those with intellectual or developmental disabilities. Wards 3 and 4 each handled up to 15 patients admitted under TDOs.

“This is when the violence increased. ... The building is not big enough, nor does it have enough staff for all of the aggressive behaviors,” the clinical employee said in an email earlier this month.

Herr said the increase in violence in Building 96 was not surprising because of its role as an acute care admissions unit, but some employees blame Hospital Director Rebecca Vauter and Chief Nurse Executive Lauren Cartwright for not providing enough security to protect them, as well as their shuffling of staff assignments.

After employees protested to state officials, Vauter asked for an independent review of the reorganization and a subsequent plan for assigning supervisors and managers among the three buildings for civil patients.

Virginia changed its leadership at Commonwealth Center for Children and Adolescents in Staunton in late 2016 and at Eastern State Hospital near Williamsburg earlier this year as the hospitals struggled to manage the pressures caused by the rising patient census.

At Central State, Herr said he is confident that the reorganization treated hospital employees fairly and “unequivocally” supported Vauter and Cartwright for their handling of it.

“Safety has been a fairly significant focus for leadership there,” he said.

Mental health advocates are “very concerned” about conditions at state hospitals, said Bruce Cruser, executive director of Mental Health America of Virginia. He also worries that pressure from the last-resort law is forcing the state to put more money into institutional care instead of expanding community services “so people don’t have go to hospitals in the first place.”

***

Angel Fuller felt overwhelmed when she walked into the crisis stabilization unit operated by the Richmond Behavioral Health Authority on Aug. 2, exactly two weeks after she was sent to Central State under police escort.

“I broke down, I was so happy to be there,” she said.

When Fuller entered the program in downtown Richmond, she scored a 17 on the screening test for depression, which falls between moderately severe and severe. By the time she left the program a week later, her score was 0, the best score.

Her original plan after leaving Central State was to find a residential program for eating disorders that would treat her with her insurance under Medicaid. According to the National Eating Recovery Center in Denver, there aren’t any in Virginia.

“That’s a significant gap,” said Carey, the state’s top health official.

One of the challenges in relieving pressure on Virginia’s overcrowded mental hospitals is finding places for patients to go when they’re clinically ready to leave, he said. “We think about the front door; we think about the back door.”

Virginia had a peak of 246 people on the “extraordinary barriers list” in May, meaning they were clinically ready to leave but didn’t have a place to live and receive appropriate care in their communities. Central State housed 37 people on the list that month, 55 in June, 43 in July and 44 in August.

Most of the people on the discharge waiting list at Central State are clients of the Richmond Behavioral Health Authority, which had 128 people on the list in the first eight months of the year, including 19 in August. Henrico followed with 50 for the year and five in August.

The same RBHA crisis stabilization unit Fuller entered after leaving Central State was among the facilities that had rejected her admission from HCA Henrico Doctors’. Henrico emergency screeners said the unit declined her admission because it would not be able to make her eat if she were not willing.

“I would voluntarily go anywhere,” she said at the end of her stay in Central State.

When Fuller left the RBHA program, she was planning to return to the home of Bill Rogers’ parents in Richmond’s West End and resume receiving services at the Daily Planet, a nonprofit safety net provider downtown. The organization sought an emergency custody order for her involuntary treatment on July 17 because of her deteriorating physical condition.

Instead, her Medicaid insurance provider is paying for psychiatric treatment at the Virginia Center for Addiction Medicine in Henrico and therapy for her eating disorder by an outpatient provider in Mechanicsville.

The Daily Planet declined to comment on her case or provide a consent form for release of medical records.

Central State records say the organization sought emergency custody because Fuller had missed doctors’ appointments and failed to pick up prescriptions, including medication to address her low potassium levels.

Fuller acknowledged that she had not picked up prescriptions and had resisted going to a hospital voluntarily, although she said she only missed appointments if she had no transportation to get from the West End to downtown.

“I wasn’t taking it as seriously as I should,” she said at Central State. “That’s my fault.”

Fuller was admitted to Henrico Doctors’ Hospital for medical treatment, but mental health workers concluded in two psychiatric screenings that she was not able to care for herself.

Police obtained another emergency custody order after “she indicated she was prepared to leave the hospital and a friend would pick her up,” said Rigsby at Henrico Mental Health.

She said she never tried to leave the hospital, but told them, when asked, she would like to leave. “Who wouldn’t want to go home?” she asked.

Fuller was taken back to the emergency room at Henrico Doctors’ Hospital, where she said she was handcuffed to a bed for nearly eight hours while the community services board looked for an available bed. Under the bed of last resort law, she was sent to Central State under a temporary detention order late on July 19.

Central State records show that the Daily Planet and Henrico Mental Health had expressed concern about her living arrangement, which includes caring for Rogers’ 93-year-old father and his mother, who is suffering from dementia. They attributed her sudden weight loss to her home environment.

But Fuller appears to be content in the Patterson Avenue home, where she has a small bedroom and a kitten named Nala. “I’ve always been happy here,” she said. “The job is difficult sometimes, but I love them.”

She said she has struggled with an eating disorder since she was 11. “It’s like there’s a monster in my head,” said Fuller, confessing that even after her ordeal, “I already feel like I need to lose weight again.”

But Fuller doesn’t think that Central State was the right place for treating her problems.

“They were probably less equipped than any of the other places they could send me to,” she said. “I lost weight while I was there.”

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