Vista del Mar Hospital must stop admitting involuntary patients due to repeated failures

A private Ventura hospital can no longer treat involuntary psychiatric patients under a suspension that starts Monday because of repeated issues with patient care, including deaths, discharges against medical advice and physical restraint in violation of policy, county officials disclosed.

In an Oct. 9 letter to Vista del Mar Hospital CEO Colton Reed, acting county Behavioral Health Director Loretta Denering cited two dozen issues centering on negative results, failure to meet requirements and "chronic and continuing" errors since at least 2021. Denering said she was suspending the hospital's authorization based on those issues and a "lack of progress" by officials at the psychiatric facility to correct the problems.

Reed did not return three telephone calls from The Star seeking comment.

Ventura County will have just one hospital authorized to admit psychiatric patients on an involuntary basis after the suspension takes effect at 8 a.m. Monday, leaving the 43-bed Hillmont psychiatric unit at Ventura County Medical Center as the only local option.

Vista del Mar has traditionally admitted both adolescents and adults. The institution has 87 licensed beds, according to state records. It is the only psychiatric hospital in the county that admits adolescents, meaning youths being treated involuntarily will have to go elsewhere.

Vista del Mar is losing its designation to treat and evaluate involuntary patients under the Lanterman-Petris-Short Act, a landmark California law that allows forced treatment under limited circumstances. The action lasts until Dec. 5, when Denering intends to ask the Ventura County Board of Supervisors to confirm the decision and terminate the hospital's authorization.

The hospital will remain licensed and voluntary patients may still be treated there, according to Denering's letter.

Hillmont's medical director, Dr. Jason Cooper, said he expected that the suspension would mean longer waits for patients in emergency rooms before they can get into a psychiatric hospital and more placements in hospitals outside Ventura County.

Denering cited a series of issues arising directly after patient discharge as well as during hospitalization. Included is the May 2022 "unsafe discharge" of Camarillo man David Hoetzlein, who is suspected of killing and dismembering his mother shortly after his release.

In June, county Behavioral Health Director Scott Gilman issued a notice to Vista del Mar that the institution had violated patient rights. He cited the Hoetzlein case but also said state officials had substantiated violations resulting in patient-on-patient assaults, disclosure of protected health information, patient injury and improper administration of anti-psychotic medications.

Denering has taken Gilman's spot while he is on leave for undisclosed reasons.

Her letter cited 22 findings involving problems with care inside the facility and errant planning for discharge. She said two patients died within days of discharge, one patient was released with another patient's medications, five patients were restrained or secluded without a doctor's orders and a patient's allegation of rape within the hospital was not reported. Additionally, several patient units were operated without the required level of staff, she said.

Two of the findings involved what were described as continued and chronic errors. They involved the discharge of patients despite their doctors' wishes and the fact that legal orders holding them were still in effect.

The hospital submitted a plan of corrective actions in response to the notice that Gilman sent four months ago, but Denering found the response inadequate.

The response indicates staff training has been upgraded to address findings on planning for patient discharges, administration of psychotropic drugs, patient privacy and prevention of suicides.

Based on the response and subsequent information the county continues to receive about the hospital's practices, officials could not find evidence of a "detailed, reliable and routinely monitored plan" to protect patient rights, Denering said in her letter.

Instead, it appears that Vista del Mar is taking a "reactive strategy," letting problems continue until they come to the attention of regulators before the institution drafts a plan of corrections, she said.

Denering said frequent staff changes result in deficiencies being blamed on former employees, while requests for necessary equipment are unheeded or deferred to corporate officials versus those in charge of the facility's day-to-day operation.

Denering indicated that she was taking the action at least in part because patients receiving care under the Lanterman-Petris-Short Act’s involuntary treatment provisions are uniquely vulnerable.

"They usually have not sought out treatment and enter your facility in a stage of their illness that prevents them from being effective advocates for their own rights and needs," the letter says.

Denering informed officers of the county Behavioral Health Advisory Board about the action Monday, said Janis Gardner, chair of the panel. She knew of no complaints about the hospital that had come to the advisory board, but said the group would be monitoring the outcome of the county's action.

"Our concern is, and always will be, that the community at large and clients are safe," she said.

Kathleen Wilson covers crime, courts and local government issues for the Ventura County Star. Reach her at kathleen.wilson@vcstar.com or 805-437-0271.

This article originally appeared on Ventura County Star: Vista del Mar Hospital can no longer treat involuntary patients