Abuse At Ingleside Campus Hospital
Rosemead, California

Abuse At Ingleside Campus Hospital
Rosemead, California


From the Desk of Kathi Ann Stringer
Corona, CA 92882

January 4, 2005

Patients Rights for Los Angels County

Attn: Director, Carol Matthews & Supervisor, Mona Sparks

Dear Carol and Mona,

This letter is follow-up per my conversations with you today, and with Stacy and Larry while inpatient at Ingleside Campus Hospital between 11/28/04 to 11/30/04. This letter is not a grievance but a complaint per W&I: §4900 (c). This hospital as defined by Health and Safety Code: §1250 is in non-compliance and operating with numerous patients’ rights violations along with other violations of other ordinances. I am also requesting the Director of Mental Health for LA to issue violations of findings per W&I: §5326.9(a). All information of the events were charted on the original grievances forms at the hospital and copied onto this letter.

I recall in our conversations that you are working with the hospital nursing director, John Zimmerman and relying on him to do the administrative investigation. I strongly object to this because as you recall, and I have restated this within the compliant, I stipulate that he is a liar and appears to play both sides of the fence to appease patients’ rights while protecting his hospital. W&I code §5500(a), §5510(6(2)), §5520, §5522, §5530, §5540, §5541, §5542, §5550 allows your office to conduct this investigation personally without having to rely on John Zimmerman’s findings, which I believe, he will adjust to protect the hospital.

Quiet Time – As you recall, staff is arbitrarily turning off the phones during “Quiet Time.” The hospital is claming Quiet Time as part of the program; same as a therapeutic group would be part of the program. The difference is, a therapeutic group has a program facilitator to move the group along. And, during Quiet Time, the only thing that is getting moved along is the patients into a mandatory type of seclusion, into their rooms. Staff is using this Quiet Time as their lunch hour and supper hour to rid themselves of the patients. And, staff is very protective of their Quiet-Time/Lunch & Supper-Hour by scolding patients when they leave their rooms and walk in on them when they are eating their lunch. This “Quiet Time” must be abolished because it invites staff (new staffers/fading memories) to assume that it is mandatory for all patients to be in their rooms. It is a no-brainer that patents can go to their rooms at anytime without staff needing to ‘remind’ them. For staff to say, “Quiet Time, go to your rooms!” comes of as mandatory, and vulnerable patients are afraid to create a rift. Also, I recall that you indicated that you have had no complaints about “Quiet Time.” This is not surprising. Remember, we are dealing with a population that many of them do not want to be locked up. And, many times patients’ complaints and grievances are invalidated when investigated and most surrender themselves into the system in hopelessness. These patients have been told what to do for a long time, and suffered the consequences when that they haven’t obeyed staff. Not only that, most all of these patients are not educated in the laws and regulations and assume it must be the law, and they should blindly obey staff or get seclusion/restraints/medicated, as they have in the past.

Also, I did speak with five patients and asked them what they thought about having to go into “Quiet Time” twice a day. One indicated it was okay and the other four basically “hated it.”

As you might recall, John Zimmerman wants to keep “Quiet Time” but will remind staff that this is voluntary. I again, object to this for the reasons stated in this complaint, and this voluntary would be short lived at best.

Also, I was illegally restrained on my bed when staff hands held me down to inject me with Haldol for sitting in the Dayroom. (I am allergic to Haldol.) I was also illegally coarsest and under duress to take medication under the immediate threat of getting an injection of Haldol.

The major infractions are:

  1. Staff is body-slamming patients – using deadly and excessive force.
  2. Drugging patients for convenience of staff or as punitive measures.
  3. Threatening patients with seclusion/restraints/medication when the criterion is clearly not met.
    W&I: §5008 (m)
  4. Possibly mixing up patient medical charts.
  5. Failure to post large Patients Rights Regulations by the phones (hidden).
  6. Failure to turn on phones during visiting time when no groups are in session.
  7. Failure to post in chart, or have a mechanism to log medication that a patient is allergic to (via summary sheet in transport or on intake).
  8. Refusal to double-check if a patient is allergic medication (Haldol) when the patient is asking for intervention from forced drugging.
  9. Mandatory Quiet Time / Voluntary Quiet time – under duress.
  10. Staff lack of respect and dignity to patients.
  11. Social worker – Failure to voluntary give patients’ discharge papers with the required diagnosis, prognosis, medications, and comments.
  12. Denial of rights when criteria are not met.
  13. Issuing standing orders for denial of rights instead of issuing an order for behavior criteria and periodic review to restore rights denied.
  14. Violation of right to be free from harm, and in a therapeutic environment that promotes wellness.
    Civil Code §43
  15. Failure to give patient advisement during intake – reason for hospitalization.
    Title 22 §71515
  16. Failure to give patient an advisement in a modality in which the patient could read the advisement (very bad hand writing – staffers also could not read it.)
    Title 22 §71515
  17. No wrist band was attached to me for patient identification
    Title 22 §71515 (g)
  18. Several staff not wearing name tags or they are covered up. Had to ask for names
    Title 22: §71521 (d)

Corrective Action Requested

Corrective Action must address revision of documented policy, testing, frequent training (Health and Safety Code – 1276.4(d)(f)), and accountability to prevent staff non-compliance and patient emotional and physical injury, patient assessment by trained RN, and other measurable objectives in the following:

  1. Address all 18 items above and all items in this complaint for corrective action.
  2. Respond to each complaint and action taken to assure the violations will not reoccur.
  3. Patients’ Rights role (the exact steps) in monitoring this hospital for compliance in the future.
  4. Examine all current policies in place concerning use of restraints/involuntary medication and request necessary revisions to prevent staff non-compliance and patient emotional and physical injury.
  5. Bi-weekly – Frequent in-service training addressing the current statues and regulations provided by law.
  6. Develop a study packet and quiz for staff, and retest all staff periodically (written and oral) to insure quality compliance, and track score results though the quality department.
  7. Develop a concrete plan with measurable objectives that address, at a minimum, the complaints in this letter, and a mechanism in which to measure continual quality improvement.

You have my complete cooperation to help resolve this problem within the Ingleside Campus Hospital. Once you have investigated and negotiated a framework for Corrective Action, please advance the results to my desk for consideration. Please respond by February 1, 2005 because this issue and corrective action is very important to protect patients in a vulnerable setting.

I am also sending a CC to Riverside County Mental Health Department Management and Riverside County Hospital Management due to the risk/liability of sending beneficiaries/clients to this hospital until corrective action is carried out to satifisation.

Thank you in advance,

Kathi Stringer
Kathi's Mental Health Review http://www.toddlertime.com Far South Director for California Network of Mental Health ClientsRiverside Quality Improvement Committee (QIC) §1810.440 Participant Riverside County Western Regional Board Member

Donna Dahl – Program Chief of the Riverside MHP
Theresa Galvez – Chief of Riverside Patients Rights
Riverside ETS management personal – Deborah Johnson, Anna Fuzie


While Inpatient Ingleside Campus Hospital
Written 11/28/04 to 11/30/04

  1. 12/28/04 Time 2:00 PM.
    Patient Chart/Name Mixup
    During intake, The only chart I noticed on the intake table had a name “Katrinia” affixed to it. It looked like the chart was meant for me. I asked who the chart was for, and Joseph said it was my chart. I was concerned since I am not Katrinia and reasonably suspected there was a mix-up between me and another patient named Katrinia. I said, “That is not my chart, I am not Katrinia. My name is Kathi.” Joseph enquired if I ever went by any other name, or nickname. I said, “No, I’ve never heard of that name before.” Joseph said, “Well, that is your name and it will be the name we call you. If you prefer us to call you by another name, we can do that.” I was stunned from his patronizing comment I answered, “No, I don’t have nick name or other name. My legal name is Kathi Ann Stringer, and that is the same name on my Medicare Card.” Joseph patronized me again and said, “That is no problem, we can call you “Kathi” if you prefer, now this discussion is over concerning your name.” I indicated to Joseph that didn’t feel comfortable answering any more questions until I was satisfied that the chart was mine or someone else’s. However, in a rapid sequence of interruptions, Joseph provided little chance for me to express my self. (Joseph later told me that reason he doesn’t give any patients a chance to express themselves is because it is a tactic he uses to “keep patients focused and on track.”)
    Authority cited:
    W&I §5325.1
    Title 22: §71515 (g)

  2. 12/28/04 Time 2:05 PM.
    Consequences for Entering Dayroom During “Quiet Time.” Seclusion & Restraints
    During intake, staffer Joseph explained the “Program Orientation.” I was told that I was to stay in my room for one hour – “Quiet Time” every day from 1PM to 2PM. I indicated that was a form of Seclusion. He indicated that it wasn’t, because the Dayroom is NOT part of the program. He went on to say that if I must leave my room, I could stand in my doorway or hallway, but anywhere else was strictly off limits during Quiet Time. I indicated that was a form of Seclusion to restrict a person into a specified area that was part of the normal program. I attempted to convey that the Dayroom also houses the Nurses Station. Joseph repeated the ‘house rules/policy’ and I was not to leave my room during Quiet Time. I said that, “This is a form of seclusion and patients cannot be put into seclusion unless there is a sudden marked change in behavior, and imminent risk of serious bodily injury to myself, others, to destruction to community property.” I continued, “If I were to go into the dayroom during this “Quiet Hour,” would I put into Seclusion and Restraints?” Joseph said “Yes, if you were to go into the Dayroom during “Quiet Time.” I indicated that I wanted to file a complaint with Patients’ Right’s because this was not legal. Joseph responded, “Are you being threatening now? Keep saying things like that and I will make a call to the psychiatrist and have you medicated.”
    Authority cited:
    W&I: §5008(m); §5325.1(a),(b),(c),(h); §5332(e); §5525.2; §5326.5(b)
    Civil Code: §43
    Health and Safety Code: §1180.1 (a),(c),(d),(e); §1184.4(k)
    Title 22: §71505, §73080, §73012.2, §71005, §71055

  3. 12/28/04 Time 2:10 PM.
    Refused Assistance to Make Call to Family on Arrival.
    At the end of intake, Joseph and a female staffer asked if I wanted someone notified that I was in their hospital. I answered, yes, Cristina Cabrera and I gave them her phone number. A few minutes later a female staffer returned and said their phone won’t allow them to dial out the number without dialing “1”. I said it was only to Corona. Staff said it should work but said I would have to ask my Social Worker the next day because they would not make the call for me if long distance. I said they shouldn’t accept ANY transfers from other hospitals if not willing to follow regulations and the courtesy of notifying my family of my whereabouts. Staff refused to make the call.
    Authority cited: W&I: §5170.5
  4. 12/28/04 Time 2:20 PM.
    Patients Rights Not Posted per Regulations
    After intake, I was trying to call Patient’s Rights. However, the phones were turned off for “Quiet Time.” In the meantime I was looking for the Patient’s Rights poster for a list of Patients Rights with the local and state capital numbers. I couldn’t see anything in plain view of the phones except a tiny 8x10 frame screwed to the wall with red paper and black ink in small font (ever tried to read red on black?). Half the information was in English and the other half in Spanish. It was so small; I could not read any of the information except the Patients Rights Number, which was so blurry I had to ask another patient for help. This is of concern since many patients are heavily medicated, and cannot read the letters/font, except as an annoying blur.
    Authority cited: W&I §5325
  5. 12/28/04 Time 3:30 PM.
    Patients Rights Handbook Not Given & Refused
    I remembered that even though I could not read the 8x10 posted ‘patients rights’ (red paper/small black font) I should have a Patients’ Right’s Handbook. I checked all the papers that were given to me. I found only these items (1) Program Orientation, (2) Pain Management, (3) Advanced Directive, (4) Patient Responsibilities and, (5) Inpatient Admitting Terms, BUT no Patient Handbook. When I notified the nursing station, the staffers just looked at me and ignored what I said. When I asked again, a staffer closed the upper half of the nursing window to cut me off from the nursing station. Later that day, I did not get a Patient Handbook when Joseph overheard me making a complaint to Patients Rights on the telephone, and he gave me one. When Joseph gave the handbook to me he said, “All you had to do was ask for one.”
    Reference cited: W&I §5325(i)
  6. 12/28/04 Time 5:40 PM.
    Family Not Notified
    I requested a phone that didn’t take money since I didn’t have any. In these cases, staff must make arrangements to help patients make those calls. Staff refused to give me access to a phone that did not require money. My family was not notified.
    Authority cited: W&I: §5170.5
  7. 12/28/04 Time 6:00 PM.
    Illegal Quiet Time - & Convince of Staff
    Staff announced that all phones were turned off at 6 PM. Staff cited “Quiet Time” (for the 2nd time that day) and all patients were to go to their rooms because it was “visiting time” for patients that have visitors coming. I heard statements from staff, “Go to your room! It is Quiet Time, you have to go to your room… You can do that later; go to your room now! One hour, you have to go to your room for one hour…. We will tell you when you can come out... Not now, you can do that later. Go now.” Patients were herded like compliant cattle into their rooms. It appeared oppressive to me. The tone in which the statements were delivered came across as threatening and intimidating. After the patients left the room, staff sent out for hot fast food in square Styrofoam containers. Five staffers were slurping up their food in the dayroom while the charge nurse “Jo” ate hers in the nursing station. Once finished with their food, staff used the patients “Quiet Time” to catch up on their work. It was apparent to me that Quiet Time was for the-convince-of-staff, and not for therapeutic reasons of the patient. It looked to me, “lock up all the crazies so we can have some peace to ourselves.” I thought it unfair that patients are restricted to their rooms and not able to visit friends/family on the phone during visiting hours. Also, not one single visitor showed up that night or the next night. The overt “Quiet Time” as staff called it, would appear to any reasonable person, to covertly be staff “Dinner Time.”
    Authority cited: W&I §5325(d); §5325.1(a),(b),(c),(h); §5326.5(b)
  8. 12/28/04 Time 6:20 PM.
    Hospital Policy vs. Law
    I did not go to my room. As an advocate with the California Network of Mental Health Clients, I was distraught by what I seeing. Jo, the charge nurse was annoyed with me because I did not go to my room. When I attempted to convey that “Hospital Policy” does not outrank law as set by legislation, Jo stated “I don’t know about that and they only follow hospital policy.” Jo continued in an angry tone, “Why don’t you just follow Hospital Policy like everyone else?”
    Authority cited: W&I §5325; §5325.1
  9. 12/28/04 Time 6:25 PM.
    Refused Family Contact Since Admit
    During “Quiet Time” when most all of the staff were eating, Charge nurse “Jo” received a call in the nursing station at 6:25 PM. Jo was giving out information for the pay phone numbers. I suspected it was my family/friend Cristina Cabrera trying to get in touch with me (Cristina later confirmed that night it was her that called and spoke with Jo). Jo was aware of my frustration with staff’s refusal not giving me access to a working phone that did not require money so I could notify my family. Jo indicated to my family/friend Cristina Cabrera that she would have to wait until after 7:00 PM because all patients were in [mandatory] Quiet Time unless they have visitors on site. My right to speak directly to my family within 3 hours of intake was violated. Cristina was not able to make contact with me to verify I was there until 9:30 PM that night because all the patients had the phones tied up. (Cristina had surfed the Internet trying to find call numbers for this hospital since none were provided, and found them hours later and then called Jo in the South Unit).
    Authority cited: W&I §5325(c); §5170.5
  10. 12/28/04 Time 10:00 PM.
    Abuse of Richard – A Patient/Peer
    Bedtime announced. I was in the Dayroom. Richard (a patient) was on the other side of the Dayroom in his wheelchair near the hallway. (Richard was missing a leg and barely survived an car accident in the early 90s – and was in a coma for 3 months, hospital for 6.5 months) Staffer Sam demanded that Richard go to bed in a strong loud voice. “Go to your room now Richard!” Richard said he wanted to stay up and came closer to the Dayroom. It appeared to me he wanted to be present in case staff would harm me when alone. There was sudden a marked change in staff tone and demeanor. Staff mood looked dark. Staffer (Sam) gripped the back of Richard’s wheelchair, jerked it around in the air, making Richard almost flip over on his side. Sam said, “I’m not messing around with you Richard! You are going to your room right now!” With a powerful thrust, Sam pushed Richard off path and into a barricade of heavy oak chairs. Sam jerked Richard’s wheelchair several times this-way-and-that, up-and-down. I was cringing as Richard’s hands were getting banged up against the oak chairs. Eventually Sam cleared the chairs he scattered around while jerking Richard’s wheelchair about and forced him down the hallway toward his room.
    Authority cited:
    W&I: §5325.1(a),(b),(c)
    Civil Code: §43
    Business and Professional Code: §4521 (i); 4521.2 (C (3),(5))
    Health and Safety Code: §1180.1 (a),(c),(d),(e); §1184.4(k)
    Title 22: §71505, §73080, §73012.2, §71005, §71055

  11. 12/28/04 Time 10:10 PM.
    Illegal Doctor’s Order/Allergic Drugs to be Involuntary Injected/Threat to take Drugs/ Illegal Human/Physical Restraint/Abuse
    Staffers threaten that if I did not go to bed I would get a shot and go into “lockup.” Although apparently futile, I attempted to convey that regulations make no provision for me to go into ‘lockup’ if I choose not to go to bed. And, I just sitting there looking at the Christmas tree reflecting on the day’s events, and I was not any threat to anyone. I was feeling especially depressed and sadden that I just witnessed Richard getting abused for no good reason. At 10:15 I heard a staffer on the phone (about 40 feet away). It sounded like Jo was talking to a doctor trying to get orders of have me involuntary drugged. I heard statements like, “She is being disruptive to the unit. She is aggressive. She is hostile” Jo was painting me as a savage loose on the unit and out of control. I turned and said in a loud voice, “You need to tell the doctor EXACLTY what I am doing and not describe YOUR perception in adjectives. You need to describe my BEHAVIOR and NOT adjectives. An adjective is “hostile”, and behavior is ‘throwing a chair.” and I am doing nothing but sitting here.” Staff continued, and it didn’t look good. It appeared I was being setup for a “shot” with a matrix of lies by staff. The called ended at 10:18 PM, (a total of 3 minutes). Staff had not explained my actual behavior, nor did the doctor act responsible and ask about my behavior. I did not fit legal criteria for getting involuntary drugged. Staff comments to the doctor were distorted and based on me not being compliant with a program that is illegal in the first place. Staff said the doctor ordered a shot. A team of staff put on plastic ivory cloves with a show of force. I was taken to my room and held down. Tara touched my skin with the needle. I shouted, “WAIT!” I realized she did not tell me what she was going to inject me with. I asked her. “Wait! Before you do that, what are you giving me in the injection? She said, “It is Haldol.” I screamed, Haldol?! I’m allergic to Haldol! I have a severe reaction to Haldol You can’t inject that stuff into me! If I had not asked, I surely would have been injected with Haldol. Staff paused after seeing my reaction over being freaked out about the thought of that toxic fluid in my body. I tried to reason with them. Tara said, “You’re lying and making it up to avoid getting injected with Haldol and it is not in the chart.” [At that moment I had a flash that staff really did have me mixed up with some other patient named “Katrinia” from the point of intake.] I begged any one of them to call Riverside ETS or, Joseph who did the intake because I told him (twice) I was allergic to Haldol. Tara put the needle closer to my hip and said, “I’m not going to the trouble of looking again. She is stalling’ Hold her down.” I stressed to each one present what they are about to do is a crime. No one intervened. I kept screaming. I resisted with every fiber of my being. I jerked, wiggled, screamed for peers to come and help. I jerked violently hoping the needle would break inside my skin before that toxic Haldol entered my bloodstream. Tara demanded that all hands tighten their grip and hold me still. One staffer was pulling my fingers backwards to cause pain so I wouldn’t move. I didn’t care. I would rather every bone was broken before letting Haldol in my system. I screamed louder and louder. Finally, another staffer walked into the room and said, “Kathi, will you take some other kind of medication orally if we don’t inject you with Haldol?” I said, Yes, but no matter what you insist I take, it is under coercion and duress. I will take it orally, but only involuntary to avoid taking Haldol.” They all left. The Staff that was involved (assault and battery), in physically restraining me was “Charlie, Namor, Tara, Martain, Ben G,” while Jo sat in the nursing station approving of this crime.

    Richard rolled his wheelchair to my door and asked if I was okay. I was crying but settling down. Staff came back and demanded that Richard go to his room. “Go to your room Richard, this doesn’t concern you!” Yet, I appreciated him being there as a witness as to what more staff may do to my body. Staff turned on Richard and forced him into his room and threatened him with a shot. A staffer gave me 2 pills. I asked what they were. Staff said, “Restoril and Ativan.” I asked if the Restoril was 15 milligram and staff said, “Yes.” I asked about the milligram for Ativan, and the female staffer said, “She didn’t know but to take it.” I involuntary took the drugs and went back into the Dayroom to focus on the Christmas tree.
    Authority cited:
    W&I: §5008(m); §5325.1(a),(b),(c) §5325.2; §5332
    Civil Code: §43
    Business and Professional Code: §4521 (i); 4521.2 (C (3),(5))
    Health and Safety Code: §1180.1 (a),(c),(d),(e); §1184.4(k)
    Title 22: §71505, §73080, §73012.2, §71005, §71055

  12. 12/28/04 Time 10:40 PM.
    Illegal Use of Medication on Richard
    Later, Richard came in to check on me in the Dayroom. Staff became irate. I overheard staff say, “See! See what she is doing? She is disruptive of the whole unit. We need to lock her up and show her who is in charge here, or this will never stop.” I asked Richard to please go back to his room so staff wouldn’t distort the situation more then they already have and look for reasons to punish him. As Richard passed the nursing station, he said goodnight to staff twice. Staff began talking about giving Richard a shot. They put on the ivory gloves and an army of them went to give him a shot. He was very angry – and rightly so as it appeared as punishment for being concerned about me.
    Authority cited:
    W&I: §5008(m); §5332(e)
    Civil Code: §43
    Business and Professional Code: §4521 (i); 4521.2 (C (3),(5))
    Health and Safety Code: §1180.1 (a),(c),(d),(e); §1184.4(k)
    Title 22: §71505, §73080, §73012.2, §71005, §71055
  13. 12/28/04 Time 11:00 PM.
    Staff Threat & Ignorance of the Law
    Late at 11:00 PM “Max” the night supervisor approached me while I was sitting in the Dayroom starring at the Christmas tree. I had just overheard him tell staff I needed to be taught who was in charge. Max said, “You will have to go to bed or go into Seclusion and Restraints.” I said, “That isn’t right.” He said, and I quote, “Yes, we can because you are gravely disabled and by law anytime a person is gravely disabled we have the right to put them into seclusion and restraints.” I respond, “That would be insane because many people on a 5150 are gravely disabled, and according to you, on a whim, any gravely disabled person and be put into seclusion and restraints.” Max argued that because according to him, the fact a person is gravely disabled means they have pari-suicidal behaviors, for example, from not eating. And not eating is a form of self-dangerousness and a patient can be put into restraints for not eating, and this gave him and his staff the legal right to put a patient into restraints if they wanted too. And since I’m designated as gravely disabled, he could put me into restraints any time he wanted and for any reason.
    Authority cited:
    W&I: §5008(m); §5325.1(a),(b),(c); §5332(e)
    Civil Code: §43
    Health and Safety Code: §1180.1 (a),(c),(d),(e); §1184.4(k)
    Title 22: §71505, §73080, §73012.2, §71005, §71055

  14. 12/28/04 Time 11:15 PM.
    Grievance Forms Taken/Refused
    After Max made his statements, I went to get a grievance form and found they were all removed from the slot in the Dayroom. I asked Jo at the nursing station for a grievance form to report the information Max just stated to me in regards to putting gravely disabled people into restraints based on a whim. I was deeply disturbed that a person in a supervisory position would be so ill advised. I was thinking of the snake pit. Jo refused to give me a grievance form and threatened me with a shot again if I didn’t go to bed right away.
    Authority cited: W&I §5008(m); §5325.2; §5332(e)
    Health and Safety Code: §1180.1 (a),(c),(d),(e); §1184.4(k)

  15. 12/29/04
    Nursing Director Fails to take Action/Non-validating
    A man and women approached me who I have never seen before. He introduced himself as the John Zimmerman, the Director of Nursing, and the woman was his assistant Director of Nursing. I was asked to go into a little room and talk with them. I was under the impression John was there to validate my concerns and resolve these problems. Once in the room, John Zimmerman said that he wanted to hear what was going on, my ‘perception of it.” I went over last night’s events of staff laying hands on me and holding me down and almost gave a shot of Haldol of which I’m allergic too. John said, “But you didn’t get that shot, did you?” I said, “No, but if I hadn’t fought as hard and jerked as hard as I did, I would have. Not only that, but JACHO frowns on attempting to inject a patient with medication they are allergic too.” John said, “I know you, I know what you are like.” I said, “How could you know me? I’ve never met you before.” In a dismissive tone John continued, “I’ve heard of you, and I’ve been to your so-called website.” John went on, “No Kathi, that was not Haldol in needle, it was something else.” I said, “Then what was it John?” John shook his head over my words “John, how would you know that, you were not even there.” John shook his head and dismissed everything I said. “You were not given a shot, it was not Haldol, and we are finished here.” I left the room. I was thinking how this is seriously looks like a cover up for malpractice.
    Title 22: §71505, §73080, §73012.2, §71005, §71055
  16. 12/29/04
    Meeting with Patients Rights and Staff
    Patient Rights arrived. She wasn’t able to talk until later. At that time I shared my concerns about the many items written here. Threats of being drugged by Joseph for calling patients rights, threats of being restrained and locked up for not staying in my room during “Quiet Time,” and etc. I asked her to state, in front of me, to John that it is illegal to force people in their rooms for “Quiet Time.” She agreed and before she left, we met with John and his assistant. But before we met, John Zimmerman asked to speak to her privately and they did so for about 5 minutes. Afterwards, I was called into the room. Before I entered, I asked her privately what they were talking about. She said about the issues at hand and John wants to cooperate. We entered into the room for the meeting. She indicated to John Zimmerman that patients could not be forced into their rooms. John Zimmerman explained that patients are not forced into their rooms and it is voluntary, or suppose to be voluntary and he will talk to his staff about that. I indicated that Quiet Time needs to be abolished. John Zimmerman said that it would not be abolished. I indicated that patients are at risk for this happening again and again. I explained that even though you may do in-service training on this today, and explain staff cannot make a patient go into their rooms, it won’t be long with staff turnover and faded memories that staff will assume it is mandatory that patients are to be in their rooms, just like what I have witnessed while I was here. I continued that without an actual group going on with a staff facilitator, this is ripe for abuse to happen over and over again. Staff will continue to make assumptions patients are to be in their rooms for Quiet Time and it is especially attractive to staff for their convince to rid themselves of pesky and troublesome patients. John Zimmerman reassured this was not the intent of the hospital and patients are not being forced into their rooms. At this time I looked at the Advocate and said, “Just for the record, this guy John is acting completely different in front of you. He appears respectful, and thoughtful and concerned of the problem at hand. And, I’m telling you, it is all an act. I saw something completely different this morning when I met with him and I was alone with him and his assistant. I’m just letting you know for the record, I am not comfortable with letting John take care and overseeing this problem. I want to see some advocates in here that acutely monitoring the situation and also take statements from these patients here today concerning being forced into Quiet Time. There is a different side to John that you are not seeing.
    Title 22: §71505, §73080, §73012.2, §71005, §71055
  17. 12/29/04
    Doctor/Illegal Order
    The doctor asked to speak with me. We sat at the end table in the Dayroom. I asked the doctor, “Do you think trust is important? He said, “Yes, it is.” I followed up, “Do you think trust is important to establish a working relationship and a therapeutic alliance?” He said, “Yes, it is.” I asked, “Was it you that ordered a shot be given to me last night? He said, “Yes, I was told you were aggressive and threatening and out-of-control” I responded, “Doctor, what does threatening, aggressive and out-of-control mean to you? What behaviors was I doing? He said, “I don’t know. I was just going by what they were telling me.” I said, “Does sitting in the Dayroom looking at the Christmas tree sound threatening and out-of-control to you? He said, “No, but that is what they said.” I explained he couldn’t legally go by that. It is his responsibly, as a doctor, to ask what the exact behaviors are, and not in adjectives.” And I said, “So, they got to you, didn’t they?” He said, “Yes. It appears they did.” I said, “How do you expect to establish trust between us when you are ordering shot without the legal criteria? He said, “How can I help you Kathi? What can I do for you? What do you want from me? I said, “First of all, after last night, I don’t trust you. Second, I am an involuntary patient here and have never asked to be here in the first place. I have nothing to say to you based on the abuse so far.” He wanted to know if I felt harmful to myself. I indicated I was having a hard time separating my feelings because I was overwhelmed with everything that I have experience in this hospital so far and I can’t answer that question. He said he was going to keep me until my hold with up and then let me go. I never saw him again for any assessments of any kind after that.
    Authority cited: W&I §5008(m); §5009; §5332(e); §5325.2
    Health and Safety Code: §1180.1 (a),(c),(d),(e); §1184.4(k)
    Title 22: §71505, §73080, §73012.2, §71005, §71055

  18. 12/29/04 Time 2:55 PM.
    Refused to Discuss Dx/Tx Plan-1
    Since admission into this hospital, no staff offered any diagnosis, prognosis or symptoms. I asked my assigned Social Worker, Kathy S. for this same information. She indicated that she asked the director of nursing (John Zimmerman) who said that information is only released if the doctor okay’s it. I indicated that I have the right to that information because I have a right to be involved with my treatment plan, and I can’t be a part of my treatment plan if I do not know the symptoms, prognosis, and etc. The John Zimmerman said okay, but he couldn’t read the doctors reading. As of this writing, I still do not have this information located in my chart.
    Authority cited:
    W&I §5157(c)
    Title 22: §71213 (d); §71549 (a (1 (m),(n))) 6, (8, (A),(B),(D)).

  19. 12/29/04 Time 6:20 PM.
    Refused to Discuss Dx/Tx Plan-2
    I requested from Charge Nurse “Mary” my diagnosis; symptoms and treatment plan 3 times. She refused all three times saying someone else will have to do it. I have been waiting 3 ½ hours for this information. Staff behind the glass is just chitchatting and ignoring the request.
    Authority cited:
    W&I §5157(c)
    Title 22: §71213 (d); §71549 (a (1 (m),(n))) 6, (8, (A),(B),(D)).

  20. 12/29/04 Time Evening
    Denial of Rights Without Good Cause
    I asked my significant other, Cristina to bring 3 books. One book was titled, “California Department of Mental Health, Laws and Regulations – 2004 Edition.” That evening, Cristina called me on the patient pay phone to confirm she had dropped off the books. I looked toward the nursing station and saw the books. While Cristina was on the phone, I asked the director of nursing, John Z that I would like my books. He indicated that I can’t have them until he talks to the doctor because he is concern about me having them because I could use them as weapons. I indicated to John that the oak chairs on the unit are much more dangerous weapons then my books. He still refused to give them to me. I returned to the phone and related the current situation with Cristina and asked her to call me later to monitor my safety. I returned to the nursing station and John was speaking with the doctor. He said, “She is dangerous, non compliant and unpredictable. She wants the books and they are heavy and with her behavior she could seriously hurt someone.” I saw how this was going. I said loudly to John Zimmerman that I wanted to speak with the doctor. MHW Sam created a barrier between the nursing window and me. I went to the side of Sam. Sam pushed me away from the window again. I went around Sam again and stated, “Tell the doctor I want to speak with him and I will go sit down.” Sam pushed me away from the window again. I sidestepped to hear John’s response to my question. As Sam pushed me away again, John Zimmerman said, “I will let the doctor know that I wanted to speak with him.” I went to sit down. I could hear the lies and distortions from the Dayroom. I said loudly from the Dayroom that John needed to tell the doctor my exact behaviors, not to say “I’m dangerous.” At that point, Sam said, “She pushed me 2 times.” Then Sam made a body gesture with his upper shoulders, with this right shoulder slamming forward as a weapon, saying this is what I did. John quickly relayed the information to the doctor and said, “She is out-of-control and that she pushed my staff twice.” I heard John saying that to the doctor and I said it was a lie. Then John said, “I saw it for myself, she did push my staff twice.” A few minutes later John Zimmerman was off the phone. John indicated that I couldn’t have all my books because I am unstable and might use them as weapons. We argued. Finally John Zimmerman gave me the soft-cover book on the laws and regulations for Mental Health. I indicated to John Zimmerman that I couldn’t be denied my personal possessions without good cause and I wanted my other 2 books. I have NOT demonstrated any behavior to be denied my right to my books. If you are going to do this, you have to enter it into denial of rights State form MH 307 and quarterly on State form MH 308. John indicated he will enter into the form and I am officially denied my right to my other 2 books. I indicated that you also have to list my specific behavior and what behavior is necessary to get my books back, and this cannot be a standing order but reviewed from time to time. John Zimmerman said I couldn’t have my book at all during this admit until I am discharged. I said, “John, this isn’t right. This is punishment. If I were that dangerous, I could pick up a chair and hurt someone. Not only that, but how is it that I’m too dangerous to have books but suddenly not too dangerous on exact moment of discharge? This is punishment. John said, “No Kathi, I’m a Patient Advocate, just like you are.” John’s statement to me is clearly in conflict with the law and a conflict of interest.
    Authority cited:
    W&I: §5008(m); §5325(a),(h); §5326.1; §5332(e); §4016; §5510 (b)

  21. 12/30/04 Time 8.00 AM Approx
    Excessive Force / Abuse of a Patient “Toni”
    I saw a patient/peer (Toni) screaming as she was coming down the hallway into the Dayroom. She was extremely upset and yelling she will contact her family lawyer for being beat up. A staffer said, “What lawyer? You don’t have any lawyer!” Staff mocking her agitated her further. Toni pulled out a piece of paper and said, “Read this bitch! What does this look like to you! It’s got my family name on it and family lawyer on it! You picked on the wrong person this time. You think just because I’m poor and in a hospital you can do what you want with me. Well, not this time. Not this time! My family is NOT going to let you get away with this!….” I said, “Hey, I’m an advocate, come over here and talk to me.” She came and sat down. I asked her name and she said it was Toni. I calmly talked to her in soft tones. I explained I could help her write down exactly what happened. She would feel better. I explained if she kept yelling, they are setting her up for a shot, and then restraints. I said, “They WANT you to do this so they can chart you were violent, crazy, delusional, and disturbed and needed intervention. They will use all this against you to discredit your statements being beat-up. They WANT you to keep going off. Don’t give them what they want. I will help you. Take a deep breath. We will write this all down.” Toni’s breathing was slowing down. Just then another peer said, “I saw everything. I want to give my statements what I saw.” And then 2 other peers said the same thing about wanting to be witnesses because they have had enough putting up with this going on. I took their names and phone numbers. I continued to work with Toni until she clamed down. She had a big round knot developing on her forehead about the size of a fist. She asked for medical attention because she was worried about a concussion. Staff refused the medical request. I looked up code in the MH Regulations books and wrote it on a piece of paper for her. She showed the paper to staff and asked for medical treatment again. And, again I saw staff refuse, “No, just go sit down. Go away from the nursing station.” Toni stated to get upset again. I looked like staff was trying to get her to go off. I worked with her some more to calm her down.

    As relayed to me by a patient named ‘Toni.” I also helped her file a complaint and I personally gave the complaint to Patient Advocate Jerry. That complaint is repeated from memory below:

    Toni was lying on the couch in the Dayroom. A lighter fell out of her pocket. She quickly got up and ran into the hallway. It sounded like an army was chasing after her. She went into her room. A staffer (named in her complaint) flew around the corner, grabbed her buttocks with one hand, and grabbed the back of her collar with the other hand and then body-slammed her into the wall. Then a second time moving his hand from her collar, and grabbed a hand full of her hair in the back of her head, and then body-slammed her again face down into the concrete floor. He was about to do it again when a staffer came in and said, “That’s enough.” The abusive staffer responded, “No man! She’s got more coming!”
    Authority cited:
    W&I §5325.1(a),(b),(c),(d)
    Civil Code: §43
    Business and Professional Code: §4521 (i); 4521.2 (C (3),(5))
    Health and Safety Code: §1180.1 (a),(c),(d),(e); §1184.4(k)
    Title 22: §71505, §73080, §73012.2, §71005, §71055

  22. 12/30/04 Morning
    Request to Investigate “Body-Slamming” and Abuse
    Patient Advocate “Jerry” arrived. I met with him in a little room on at the end of the dayroom next to the patio door. Jerry said it had to be quick because he had a lot to do that day. He had 4 hearings with stack of charts in hand. I indicated I was under the impression a special investigator was going to be seeing me that day. He explained there was no time for that and to save my grievances until I get out of the hospital and they will work with me at that point. He further explained that he was only supposed to quickly reassure me they are going to address this. I indicated my concerns that if this office was correctly staffed with enough advocates to give their clients fair time. Jerry said they were staffed with enough advocates because there are about 33 of them in the LA office. I shared the there is supposed to be 1 advocate for every 500,000 in the entire population of Los Angles County. Jerry indicated that he was not aware of that. I asked Jerry if a patient getting body-slammed this morning would warrant getting immediate assistance. He said it would. Jerry asked who this patient was. I said her name is Toni, but she disappeared before you got here. Jerry left the room. Next time I saw Jerry, he was exiting the front door with John Zimmerman. I ran to the front door to catch up with Jerry. Jerry said that he is looking into it and John will be doing all the investigations. I said, “Jerry, do not let John carry out this investigation. He lied last night to the doctor saying I pushed a staffer and then denied giving my books. Do NOT trust him. I mean this. If you guys rely solely on John findings, I will ask for another investigation. He is not to be trusted. This is a severe conflict of interest.” Jerry said he would take care of it. I handed Toni’s grievance to him and said, “This is Toni’s complaint. I wrote everything down for her and also listed witnesses with their contact phone numbers.” Jerry requested that hold it till later. I said, “No, this her complaint. You are supposed to be her advocate. I do not want anything to happen to this information and it is your responsibly take it, not mine.” Jerry took Toni’s grievance.
  23. 12/30/04 Time 10 AM.
    Refused Required Discharge Information
    Social Worker, Kathy S. had told me that morning that I was going to be discharged and asked for an address the their driver could take me too. I asked Kathy for my diagnosis on all Axis and prognosis. Kathy said that it is too early to make those conclusions. I indicated that a working DSM diagnosis should have been made on intake according to the rules of getting paid by insurance companies. And, that diagnosis needed to me made even if other diagnosis were to be ruled out at a later time. You can’t hold someone without a legal DSM diagnosis. Social Worker Kathy S said she would recheck to get the information. She returned and said that, “We are not going to give you that information. If you want it, you can request that information from our records department.” At that point, I shared with Social Worker Kathy S. the W & I code that requires the hospital to make the information available on discharge. Kathy read the code and then came back a few minutes later with form “Discharge/Aftercare Plan.” This form listed Axis 1, 5 and prognosis with no comments.
    Authority cited:
    W&I: §5622 (a (1),(2),(3),(4))
    Health and Safety Code: §1262 (a (1),(2),(3),(4),(6)); §1262 (c (2))
    Title 22: §71213 (d); §71549 (a (1 (m),(n))) 6, (8, (A),(B),(D).