Eastern State Hospital in James City County (Virginia Department of Behavioral Health and Developmental Services)

Like many congregate facilities, Virginia’s state-run mental hospitals reported an increase in deaths during the coronavirus pandemic. But the “vast majority” of those deaths weren’t the result of COVID-19, according to a state watchdog group tasked with advocating for Virginians with disabilities.

The findings are raising concerns that patients are being inappropriately admitted to mental hospitals with complex medical conditions, said Colleen Miller, executive director of the Disability Law Center of Virginia. The private nonprofit has been designated as the state’s protection and advocacy system for patients with disabilities since 2013. But for the last three years, it’s also collected data from critical incident reports submitted to the Virginia Department of Behavioral Health and Developmental Services, which oversees 11 mental health facilities across the state.

Those reports show that deaths have been steadily increasing in state-run mental hospitals since 2014, when Virginia passed what’s commonly known as its “bed of last resort” law. Under state code, Virginia’s psychiatric hospitals are required to admit patients after an eight-hour period if a bed can’t be found at another facility (including private hospitals with behavioral health units).

There’s broad consensus that the law unintentionally caused admissions to surge at already crowded state-run facilities. Virginia code also allows patients living with dementia to be involuntarily committed if they’re going through a mental health crisis. Over the years, Miller said that’s likely resulted in a growing number of what DLCV calls “inappropriate” admissions — patients who would be better served in settings equipped to provide medical care. 

“None of the psychiatric facilities run by the state are medical hospitals,” she said. “They’re just not in the position to deal with those kinds of acute conditions.”

For DLCV and other advocates, the problem is earning new scrutiny amid another reported increase in deaths. In the fiscal year that ended in June 2019, deaths at state-run hospitals declined for the first time in five years, dropping to 56 after a high of 76 the year before. In fiscal 2020, though, the total count rose again to 62.

Despite the pandemic, most of those deaths weren’t due to COVID-19, the organization reported. Piedmont Geriatric Hospital in Burkeville, for example, recorded a total of 25 deaths — more than a quarter of the state total. Only seven of those 25 were “due to or concurrent with” a coronavirus infection, according to the hospital’s own reporting.

“And COVID is a problem that’s hopefully unique to 2020,” Miller said. “But it doesn’t explain the fact that what we think are inappropriate medical admissions have been going on for years.”

Currently, there’s scarce information on the number of people admitted to state-run mental hospitals with complex or long-term medical needs. Lauren Cunningham, a spokeswoman for the Department of Behavioral Health and Developmental Services, said the agency doesn’t have a standard definition or category for those kinds of patients, making the number difficult to quantify. 

“It would be fair to say that in general the number of medically complex or long-term care patients has increased in state hospitals since the bed of last resort legislation went into effect,” she wrote in an email last week. DBHDS also couldn’t provide data on the number of patients admitted with dementia, a term no longer used by the Diagnostic and Statistical Manual of Mental Disorders. 

“The process for pulling that data is more complicated than I realized even when we spoke last week,” Cunningham wrote. “As I mentioned then, part of this is because it requires pulling multiple diagnoses.” 

The Disability Law Center has been trying to quantify the problem with different measures, including the number of deaths at state mental hospitals within 90 days of admission. In fiscal 2020, there were 17, or 27 percent of all recorded deaths.

For the last three years, the nonprofit has also been collecting data on patients admitted to state mental hospitals with do-not-resuscitate orders or instructions for palliative care, including hospice services. In the fiscal year than ended in June 2020, 58 percent of patients who died were admitted with those types of directives— “one of our only concrete indications that these deaths may have been expected,” the law center wrote in its latest report.

The state behavioral health agency has objected to the inclusion of do-not-resuscitate orders, which any patient can request “regardless of health status,” Commissioner Alison Land wrote in a response letter to the nonprofit. But with little available data, Miller said those are some of the only ways to assess how many patients are admitted to psychiatric facilities with serious medical needs.

“I do think the hospitals are doing the best they can,” she said. “But it’s a little startling to see someone might be admitted to a mental hospital with what’s obviously a short life expectancy.”

Those challenges are especially visible at Piedmont, a 123-bed facility that was “woefully” understaffed even before the start of the pandemic, according to DLCV’s report. “If one in five patients died at any other facility, it would be a front-page news story,” the nonprofit wrote. “Yet because the deaths occurred across a year and only impacted geriatric people, they are somehow considered ‘allowable.’”

The state only began analyzing trends related to deaths and serious incidents in spring of 2020, Land wrote. But Dr. Alexis Aplasca, the agency’s chief clinical officer, said the state’s bed of last resort legislation created ongoing challenges for state-run facilities. 

“We have basic access to medical treatment, but most specialty care we have to refer to outside providers,” she said. Before the legislation went into effect, state hospitals often had more time to coordinate a patient’s care or find a bed at another facility. But with the current eight-hour timeline, that’s often not possible.  

“There’s a real pressure to continue accepting patients at a very fast rate,” she said. “Prior to bed of last resort, these admissions were more planned. So it was easier to identify these medical conditions and at least start the appropriate treatment.”

The pandemic also made it far more difficult for patients to leave state hospitals. Miller said one of the law center’s clients wanted to leave Piedmont to see an eye care specialist last year, but wasn’t allowed because the facility was on lockdown due to an outbreak. The patient later died, though the nonprofit is still investigating whether the cause was related.

In other cases, outside lockdowns made it difficult to discharge patients. For months, many of the state’s nursing homes and assisted living facilities refused to accept new residents, prompting Land to send out an urgent request for assistance. As a result, many geriatric patients were unable to find beds in settings that could accommodate more complex medical needs.

“Ultimately, most of those folks are best served in a private hospital,” said Bruce Cruser, executive director of the nonprofit Mental Health America of Virginia. That’s often a challenge the state’s network of services isn’t able to handle.

“The state hospitals are ill-equipped to provide intensive medical care,” he said. “But private hospitals aren’t set up for long-term health care. So it’s definitely a challenge for our system.”