Imperfect Paradise presents LAist Investigates The Truth Inside California's Nursing Homes

Antonia Cereijido  00:00

[music in] You're listening to Imperfect Paradise from LAist Studios. I'm your host, Antonia Cereijido. Occasionally, we're going to bring you an episode that's a little different. Today, a special single episode deep dive with one of our LAist reporters. Elly Yu spent months investigating nursing homes in California and uncovered thousands of people with serious mental illness living in facilities not intended to care for mentally ill patients. Many of these patients are not actually elderly.

Travell Jackson  00:31

[audio clip] I've had a patient as young as 19 years old, 22.

Antonia Cereijido  00:36

For people working in these nursing homes the conditions can feel dangerous.

Travell Jackson  00:40

[audio clip] They ran faster and moved better than I did.

Elly Yu  00:45

Nursing homes have become de facto mental health facilities because they're just not enough places for people to go. [music out]

Antonia Cereijido  00:52

That and more coming up on Imperfect Paradise from LAist Studios.

Antonia Cereijido  00:58

LAist reporter, Elly Yu, spent six months examining complicated federal data to uncover this alarming trend about how nursing homes primarily funded by public dollars have become de facto mental illness treatment centers. Elly worked with APM Research Lab and the California Newsroom on this investigation. Elly first broke the news in September. She joins us here on Imperfect Paradise to take us through this issue and bring us through the history of how mental health has been treated here in the state.

Antonia Cereijido  01:27

Hi, Elly. Thank you so much for joining me.

Elly Yu  01:29

Thanks for having me.

Antonia Cereijido  01:30

So as I was reviewing your investigation, I was really drawn to the story of a licensed vocational nurse you spoke to named Travell Shawnte Jackson, and she experienced a lot of what you uncovered in these reports firsthand. So can you tell me a little bit about her?

Elly Yu  01:43

Yeah, Travell is a nurse who I met who has been in the industry for two decades. She's 49, lives in Hawthorne, and has worked all over Southern California. She's very much a tell it like it is person.

Travell Jackson  01:54

[audio clip] I guess I'm just a little bit of a- I get bored easily. So I've worked in pediatrics, hospice. I've worked in uh, I have to call it genres.

Antonia Cereijido  02:04

But you met her because she was working at one nursing facility in particular, right?

Elly Yu  02:09

Yes, Hyde Park Health Care Center. It's a nursing home about 10 miles southwest of LA. Travell, she started working there in March of 2022, and she was doing basic care, you know, helping people with their medications, feeding people, checking on vitals, basic nursing care for residents. A lot of nursing home residents need help, you know, just like daily living activities, getting to the bathroom, showering, eating, that kind of thing. So that's the type of stuff she was used to doing and somewhat doing at the facility.

Antonia Cereijido  02:37

Yeah, but this facility was different than other facilities.

Elly Yu  02:41

[music in] Yes, Travell Jackson said, you know, On the outside, this facility looks like just any other nursing home. You wouldn't really think much about it if you walked past it or looked at it. But on the inside, she said most of the patients weren't what you typically think of when you think of a nursing home.

Travell Jackson  02:58

[audio clip] Schizophrenic, psychosis, bipolar disorders, some would be yelling, some would be on lithium, sometimes patients would be so bad, we'd have to assign just one nurse to that patient all day, to sit with them, because they'd be so disruptive. And that's how our day went. All the time. [music out]

Elly Yu  03:23

She said a lot of people there just were very isolated.

Antonia Cereijido  03:27

And also notably that they weren't elderly folks, who are the people that you would expect to see in a nursing home. Like how old were these residents?

Elly Yu  03:35

Yeah, she said most of the residents there were in their 40s, 50s, 60s. So to give you an idea of the average nursing home resident is like in their 70s, 80s.

Travell Jackson  03:44

[audio clip] I've had a patient as young as 19 years old, 22.

Antonia Cereijido  03:50

Oh my gosh.

Elly Yu  03:51

So she was used to caring for people with like cognitive issues like dementia.

Travell Jackson  03:55

[audio clip] I'd say a 90 year old woman would probably have episodes of screaming in her dementia.

Elly Yu  04:02

But she was not used to caring for people who are more able bodied, who had serious psychiatric illnesses.

Travell Jackson  04:08

[audio clip] That's different than a psychotic person yelling, screaming, fighting, biting and throwing feces, that is 35. [music in] They ran faster and moved better than I did. They were able to climb fences. They were able to fashion weapons out of things. They were able to do a lot of things. You're dealing with so many different behavior issues. Patients running around screaming, yelling, disrobing, defecating in the hallways, on themselves. It was an eight hour adrenaline rush every day. There are no protocols in place to keep staff from being assaulted. There are times when you are understaffed and you are the only nurse in a building for hours, for shift upon shift. [music out]

Antonia Cereijido  04:22

I mean, put another way, the nurses weren't being trained on how to deal with the patients that they had.

Elly Yu  05:09

That's what Travell said. Yeah, that they were, this was not a patient population that they had the training to deal with.

Travell Jackson  05:16

[audio clip] There should be additional licensing. There should be additional training. There should be- Let's say this- I was orientating a registered nurse to come on as my supervisor. Once she found out that the population was what it was, the lady didn't stay the rest of the shift. She walked out.

Elly Yu  05:41

She said a lot of the people there who did have serious mental illness were quote unquote, "regulars" and had been there for a while.

Travell Jackson  05:48

[music in] [audio clip] You know, sometimes I would see someone and then I'd ask them, How did you end up here? All the time. How did you end up here? Where's your family? Some were just too far in their illness to give me a straight answer. It's just sad. And you wonder- I always say, someone has to be looking for you. [music out]

Antonia Cereijido  06:10

You know, it's- to me, it's really moving hearing Travell talk about this, because I obviously understand how it was a very scary situation for her and the other health providers. But I'm curious about for the mentally ill patients themselves, like, how was their care at these facilities?

Elly Yu  06:23

Yeah, I wasn't able to speak directly to any patients there or family members of patients with serious mental illness at the facility. It's very hard to get access to these types of facilities. But there have been a number of incidents there in public records. I mean, in one case, a resident left unmonitored and was found with blunt head trauma and in a vegetative state. He was missing for 23 days. One thing that Travell told me was that patients with mental illness weren't getting what they needed at the facility. It wasn't the right fit. We did reach out to the company who owned Hyde Park during this time. They didn't get on the phone with us, but in a statement said they were focused on providing a safe environment for patients and staff. They also said they believe they have the training programs to minimize dangerous incidents. But as it turned out, it wasn't just Hyde Park where we were seeing an influx of patients with serious mental illness.

Antonia Cereijido  07:13

Yeah, so like, how big of a trend is this? Like, how big of a problem is it that people who need mental illness treatment are being routed into nursing homes?

Elly Yu  07:23

Yeah, at first, I was wondering if it was just a few facilities that had this many people with serious mental illness. Turns out, it's not just a few. We found almost 100 facilities in the state that over 50% of residents there had a serious mental illness.

Antonia Cereijido  07:38

Wow. That's so many.

Elly Yu  07:39

50%. So like half the res-, you know, half the population. And that obviously changes what kind of facility that is. We also found that overall in the state, one in four residents in a nursing home had a serious mental illness- bipolar disorder, schizophrenia, or psychotic disorder were the diagnoses we looked at. And that number has been rising over the last decade as well. I spoke with Tony Chicotel. He's with the California Advocates for Nursing Home Reform. He characterized it this way.

Tony Chicotel  08:06

[audio clip] For most residents with serious mental illness in nursing homes, the nursing homes just serve as a warehouse, keeping them alive, keeping them fed and sheltered and out of the streets, and out of people's way.

Elly Yu  08:18

[music in] The stark reality is that many nursing homes have become de facto mental health facilities because there are just not enough places for people to go.

Antonia Cereijido  08:28

And that's partly due to like, the history of how we're funding mental illness treatment in the state, right?

Elly Yu  08:34

Yeah, you have to go back to the early 1950s to kind of understand all of this.

Antonia Cereijido  08:40

Well, we're gonna get into that after this break. You're listening to Imperfect Paradise. [music out]

Antonia Cereijido  08:55

[music in] This is Imperfect Paradise. I'm Antonia Cereijido. When we left off, LAist reporter Elly Yu told us about nurse Travell Jackson's experience seeing more and more mentally ill patients come into the nursing home where she was working, and then explained how this is happening all across California. Elly's investigation found that overall in the state, one in four residents in nursing homes had a serious mental illness. And Elly is back to talk through her investigation. [music out]

Antonia Cereijido  09:25

How did you learn about this story?

Elly Yu  09:27

So I used to be a health reporter. And I think the pandemic happened and then like nursing homes were just devastated by COVID. I mean, so many people died and I was getting a lot of tips during the pandemic about nursing homes like not being prepared, or like not testing people. I was looking into a nursing home chain and I was obviously looking at violations of patient care. I was looking at state issued citations. I noticed that there was- there were a lot of citations I was seeing involving patients with serious mental illnesses, patients in their 40s/50s. And I was like, why are people with serious mental illness in these facilities? [music in] So then I submitted a Freedom of Information Act request to the federal government, to the Centers for Medicare and Medicaid Services, because they keep all this resonant data, because nursing homes who get that money have to submit this data. And that's the vast majority of nursing homes. And I finally got it back. It was massive amounts of data. If you think about like, information about all residents in the state of California, [Antonia: Oh, my gosh.] for 10 years. [laughing] So it's a lot. [Antonia: Yeah.] I could not even open it on my computer. My Excel kept freezing. But once I finally partnered with the APM research lab to take a look at this data, they have the right data programs to open all these documents. I also worked with the California Newsroom. And that's when we discovered all these trends. [music out]

Antonia Cereijido  11:01

Did you talk to people about just like, how we got here, like what led to this?

Elly Yu  11:06

Yeah, I talked to a lot of experts who say that it's just, it's like a symptom of how we've treated mental health care, just as a society, as a country, as a state. And we- You kind of have to go back to the early 1950s to kind of understand all this. You know, back then people were housed in like, what are called asylums, or like state run psychiatric facilities. In 1955, half a million people in the country were living in state funded, and state run psychiatric institutions. So people would send their family members away and just like, never hear about them. And back then there was a movement to start deinstitutionalizing people because there was this consensus that keeping people sort of shut away from the rest of society in these asylums was inhumane, and like, there were terrible things happening at these facilities, a lot of abuses. In the state, it was a big issue. In the 1960s, we passed the Lanterman Petris Short Act, which basically ended indefinite involuntary commitment, which was happening to people like, you know, against their will.

Antonia Cereijido  12:10

And surprisingly, at the national level, JFK actually played an important role in the deinstitutionalizing movement.

Elly Yu  12:17

This was really personal for him. He had an older sister named Rosemary, who had disabilities. And, you know, in her 20s, she had a lobotomy, that left her like, permanently incapacitated. And so he wanted to create a system that helped treat people in, in communities and close to their families. And she- I think she lived in an institution for the rest of her life. [Antonia: Wow.] [music in] So there was a movement to stop this, right, to, to, like, get people out of these facilities and into the community and living in the community. At the same time, around the same time, there was a lot of advances in psychiatric medications, which would help manage a lot of symptoms for people with mental illness. And so there was this idea that people can live in the community in, in, you know, home like settings, with their families, [music out] and not be shut out, you know.

Antonia Cereijido  13:09

Right. So in the 50s, it was- People were in institutions. The idea was, let's get people out of these institutions and put them where?

Elly Yu  13:20

Yeah, I mean, there were supposed to be like community facilities to help care for people with mental illness. There were supposed to be, you know, services to help people live in their home communities.

David Grabowski  13:31

[audio clip] The original policy of closing the state psychiatric hospitals really comes from a good place.

Elly Yu  13:37

I spoke with David Grabowski. He teaches healthcare policy at Harvard.

David Grabowski  13:41

[audio clip] Everybody wants care in the community, and many of these individuals can be effectively and safely cared for in the community, if you have those community resources in place to actually do the care. And we dropped the ball on the second part of that. We closed the state psychiatric hospitals in a lot of markets around the country, but we never built that home and, and community based resources for psychiatric populations.

Elly Yu  14:10

But this community mental health system just never fully got funded in a way that was envisioned.

Antonia Cereijido  14:17

So it seems like the federal government was like, We don't want to fund these big institutions. But they didn't provide funding for more community based programs.

Elly Yu  14:26

Yeah, in 1965, Medicaid is introduced. That's the state and federal like, public insurance program. And in it, the law specifically wanted to de- incentivize institutionalizing people with mental illness. And so if you are a psychiatric facility, you can't get federal funding. Many hospitals, for instance, do get Medicaid funding if you have like a physical illness. And the idea was to de-incentivize caring for people in institutions and to help people you know, incentivize states to care for people in the community.

Antonia Cereijido  15:02

That's like such a wild way of thinking, of just being like, if we don't pay for it, like, they'll figure out this like, magical way of doing it, but no one ever thought about how it was going to get paid for.

Elly Yu  15:10

It's a big pain point for a lot of state leaders because they say it's prohibited them from being able to pay for treatment facilities.

Antonia Cereijido  15:17

For people with mental illness. [Elly: Yeah.] So now, like, a lot of, a lot of institutions have become like, de facto places for people with mental illness, like you said, jails, hospitals, and of course, now we're talking about nursing homes. I mean, how, and how are they actually ending up in the nursing homes?

Elly Yu  15:33

Yeah, so our investigation found that over 90% of people who are in a nursing home end up coming from the hospital. So we know that a lot of people use ERs for care, for primary care, for psychiatric care, because it's been, I mean, ERs have kind of become the ground zero for a lot of society's problems like for, if people don't get preventative care, they're ending up in the ER. And that's what I was hearing from, you know, people who worked in ERs that people with psychiatric issues- they've seen a lot of people come into the ERs and then either for a physical issue that was like, not being cared for, or a psychiatric issue, and then they get hospitalized. And then when it gets time to leave, hospital workers are telling me that there's very few places that can care for people with serious mental illness that seem like a good fit. And I've talked to social workers who said nursing homes, you know, might not be the best fit, but it's like the next best option that they have. And so they'll send people there.

Antonia Cereijido  16:33

[music in] After the break, Elly explains what's being done to address this problem. You're listening to Imperfect Paradise. [music out]

Antonia Cereijido  16:53

[music in] Welcome back. This is Imperfect Paradise. I'm Antonia Cereijido. Before the break, we were talking to LAist reporter Elly Yu about the history of mental health treatment here in California, and how we ended up in this situation where hundreds of nursing homes are taking care of our mentally ill. [music out] And Elly is back with us now to talk about what's being done to address how we care for mentally ill patients.

Antonia Cereijido  17:16

One question I have is, right now with the system we have in California, what is the best case scenario for people who are mentally ill?

Elly Yu  17:24

It seems like the answer would be complicated, but like from advocates I've talked to, the answer is actually pretty simple. Supportive housing, places where people can, you know, live, get support for their serious mental illness, get case management services, get other sort of wraparound services, but live in a home like community.

Antonia Cereijido  17:43

Is there a lot of that or like, where-

Elly Yu  17:45

There are some. There's just not enough. And there have been like board and care facilities that have been closing left and right, especially in LA, just because there's not a lot of funding for them. So a lot of those have been disappearing. So a lot of housing has been disappearing. And I mean, when I think of California, a lot of, a lot of issues kind of stem back to affordable housing. [Antonia: Mm hm. Mm hm.] And for people who do need like a little bit more care and are not ready to live independently yet, there aren't enough treatment beds for them either. But I spoke with Jonathan Sherin. He's the former Mental Health Director of LA County. And he basically told me if there was more housing, then the people stuck in these treatment facilities can move into housing. And then people who need those treatment facilities can get into those treatment facilities.

Jonathan Sherin  17:48

[audio clip] And what I'm saying to you is, if there was enough housing, and there's enough support in community, we would be able to pull people out of all of the treatment environments so that there would be plenty of acute beds, plenty of sub-acute beds or STPs. We wouldn't be jamming up the streets, the jails.

Elly Yu  18:50

People end up being stuck in these institutions, because there's nowhere to go. Like a nursing home- I've talked to, I've talked to one family member who has, her son has schizophrenia and ended up in a nursing home because of a broken bone. This was a couple years ago, but is still there. The bone is healed. But people just end up getting stuck and stuck in these types of situations. And, you know, once you're in a nursing home for a while, a lot of people end up losing their housing, too. So it just becomes kind of this cyclical- Yeah, stuck there.

Antonia Cereijido  19:21

Wow. You alluded to this earlier, but is there a push right now to make the federal government be more responsible for caring for mental illness?

Elly Yu  19:30

There's a lot of efforts, like locally. Even the LA County Board of Supervisors have supported measures so that the federal government would pay for care in these facilities. There's a lot of lobbying going on right now.

Antonia Cereijido  19:45

And then what's happening at the California level?

Elly Yu  19:48

On the state level, the governor's office has been doing a lot on mental health care. They have a plan to expand housing and treatment beds for people with serious mental illness. It just passed the legislature this past summer and that plan will go to voters in March during the presidential primary. It also includes a bond that would raise money to build and go to these housing and treatment beds. But that plan is controversial because some civil rights advocates are concerned that the money will be used towards institutionalized settings. It's just getting people off the streets and kind of out of sight out of mind versus housing, which are two separate things. Like treatment facilities and living somewhere that you consider home is very different. And they were concerned because in the beginning, when this legislation was first proposed, it said that the bond measure would go to quote, "voluntary unlocked" types of facilities. And that language was stripped the last week of the legislature and passed and so it can go to involuntary type locked facilities.

Antonia Cereijido  20:53

And a locked facility would be like an institution.

Elly Yu  20:55

Yeah. Governor Newsom has said, you know, these facilities, some that he described as like, campus-like settings would not be like, quote, "institutions of the past," but places where people can heal and thrive.

Gavin Newsom  21:06

[audio clip] We make sure they're state of the art, 21st century, regional centers of support, so that we never go back.

Elly Yu  21:15

But I've talked to advocates who say, Yeah, that sounds great. But what happens is people just end up getting kind of segregated from the rest of society. They don't have advocates advocating for them. That's when bad things can happen.

Antonia Cereijido  21:28

What's being done to help folks like Travell, who are being asked to do work that they weren't trained to do?

Elly Yu  21:33

I've talked to the Union of Health Care Workers who say, you know, this is something that they've been seeing more and more of their nurses having to serve patients with serious mental illness that they weren't trained to help. And so they've done several trainings, too. But I think their thought is, this is like, if, if this is the new population, there needs to be more efforts to like license and, and train people who are in the nursing home industry.

Antonia Cereijido  22:00

Yeah, and the consequences of that are that the nurses aren't going to stay. Like Travell ultimately-

Elly Yu  22:04

Totally. She quit. Yeah, she lasted about six months, and she left without, like, a two weeks’ notice. She was, she was done.

Travell Jackson  22:14

[audio clip] It became uh, a little too um, dangerous for me to continue on. As far as uh, finding certain things and things uh, happening to uh, patients that I just, I just couldn't watch. The nursing patients not to the psych patients. I just no longer wanted to be a part of it.

Antonia Cereijido  22:36

[music in] It's so interesting if we're thinking that the reason why all of this happened was the deinstitutionalizing effort. But the reason why people pushed to deinstitutionalize was because those spaces were, like, problematic. And so, it feels like the dream of that movement was just like, never realized. The supported housing is sort of still what they wanted in the 60s and yet we've not been able to figure it out in all of these decades.

Elly Yu  23:01

Yeah, and that's why we have people today in like these- What, what ended up happening was people just were becoming institutionalized in other places.

Antonia Cereijido  23:12

Well, Elly, thank you so much for your really incredible investigation.

Antonia Cereijido  23:17

That's LAist reporter Elly Yu on her investigation with APM and the California Newsroom. You can hear her full story @LAist.com. [music out]

Antonia Cereijido  23:36

[theme music in] Next week on Imperfect Paradise, the first of our new series, The Castle, the story that pulls back the curtain on an exclusive iconic LA landmark, the Magic Castle, and efforts to confront its problematic past.

Carly Usdin  23:51

It felt like you were back in time in a place where like, almost everyone there is an older white cis heterosexual man. It's their world that you're stepping into.

Kayla Drescher  24:01

Magic is still this microcosm of the world, but of the world in like the 50s.

Herve  24:07

I think the first, the first 2021, the vision was not clear. I was not really that impressed by the way we were doing things. And you know what? You don't want to implement bad ideas.

Antonia Cereijido  24:17

That's coming up on Imperfect Paradise. Listen to new episodes of the podcast every Wednesday, or tune in on Sunday nights at 7 PM on LAist 89.3 or LAist.com This episode of Imperfect Paradise was reported by Elly Yu. I'm the show's host, Antonia Cereijido, and I produced this episode with support from Production Coordinator Jens Campbell. Editing by LAist Executive Editor Megan Garvey and Elly Yu. Catherine Mailhouse is the Executive Producer of the show and Shana Naomi Krochmal is our Vice President of Podcasts. Mixing and theme music by E. Scott Kelly. Imperfect Paradise is a production of LAist Studios. This podcast is powered by listeners like you. Support this show by donating now at LAist.com/join. This podcast is supported by Gordon and Dona Crawford, who believe quality journalism makes Los Angeles a better place to live. [music out]