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Extracted from Consolidated Report

This investigation was originally published as part of a larger consolidated report containing multiple investigations. View the consolidated PDF for the complete document.

Sutter County Grand Jury • 2021-2022

Sutter-Yuba Behavioral Health: Behind the Times

52 pages

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⚠️ Translation Notice: This content has been automatically translated. The original English text is the official version. Translation may contain errors.

⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.

Findings 15 findings

F1 Page 106

F1. The patient rooms at the Sutter-Yuba Behavioral Health (SYBH) Psychiatric Health Facility (PHF)contain multiple Ligature Points. Among staff and administrative personnel interviewed, there was a general awareness of these issues but no apparent sense of urgency to address them.

F2 Page 106

F2. Based on site observations of the SYBH PHF Unit, various doors did not appear secure, leaving certain areas potentially vulnerable to unauthorized patient access.

F3 Page 106

F3. The perimeter fencing at the SYBH PHF Unit’s outdoor recreation area is vulnerable to the exchange of contraband, due to easy public access. It creates a sense of being “locked” in, which is not welcoming or comforting for the patients.

F4 Page 106

F4. The perimeter fencing at the SYBH PHF Unit’s outdoor recreation area is an AWOL risk.

F5 Page 106

F5. Based on site observations and interviews with staff, the Video Monitoring System at the PHF Unit is an old and antiquated system. Components of the system are non-operational including many of the cameras. Repairs of the current system are either cost prohibitive or not possible due to the age of the system.

F6 Page 106

F6. SYBH use of private security is inefficient and lacks good use of the services.

F7 Page 106

F7. SYBH Policy and Procedure of recording an AWOL and Hazard/Incident Report is antiquated. It lacks sufficient information and structure to monitor and record AWOL incidents in a concise and professional manner.

F8 Page 106

F8. Based on SCGJ observations, the signage at the County’s PHF Unit is inadequate, outdated, and in very poor shape.

F9 Page 106

F9. The beds in the Isolation Rooms at the PHF Unit are an old version that leave the patient in an uncomfortable position if restraint is required.

F10 Page 106

F10 The parking lot at the SYBH facility is in disrepair and a hazard to the public.

F11 Page 106

F11. The building and grounds at the County’s PHF Unit show lack of regular maintenance. The vegetation is overgrown. Weeds growing up in sidewalks as well as in large unplanted areas. The exterior walls, concrete walkways, garbage receptacles are dingy or outright dirty. The window information signage is unprofessional in appearance.

F12 Page 106

F12. Based on those interviewed and a review of budgetary documents, it appears some SYBH and Health and Human Services (HHS) management and key fiscal staff lack sufficient knowledge/understanding of the budget practices. This includes MHSA and Realignment funding.

F13 Page 106

F13. Based on Sutter County Grand Jury research and those interviewed, there is no regular meeting of key fiscal staff, department heads, and directors to address changing budgetary issues. Currently, this is done once a year or on an “as needed” basis. This has created some issues with timely budgetary reporting.

F14 Page 106

F14. Based on Grand Jury research and those interviewed, the existing SYBH Electronic Health Care Record System is inadequate.

F15 Page 106

F15. Based on site observations, review of county plans for the Gray Ave Building, and SYBH administration interviews, the 1965 Live Oak Blvd Building is no longer adequate to house the Psychiatric Health Facility (PHF) and other SYBH offices/programs. 96

Recommendations 20

R1
Page 107

R1. SYBH and the County must take the Ligature Points concerns seriously. SYBH needs to perform a needs assessment to clearly identify the issues and submit a comprehensive request to the County. The County, in turn, needs to share a sense of urgency and prioritize funding as soon as possible. These should be resolved by July 31st, 2022.
R2
Page 107

R2. SYBH needs to perform an assessment of all access points with the PHF Unit and address any necessary modifications to ensure proper security and controls are in place for the safety and well-being of both the patients and the staff while mitigating AWOL opportunities. These should include: the doors leading to the staff break area just south of the nurses’ station inside the PHF unit. The door leading from the breakroom to the south side of the building by the parking lot. The double doors to be replaced at the entrance of the PHF unit. Half “Dutch” door to the medication room.
R3
Page 107

R3. SYBH and the County need to take all necessary measures to ensure constant supervision and safety of the perimeter of the outside fenced in recreation yard on the PHF unit to resolve the potential exchange of contraband. The simple practice of 1:1 of a mental health care worker to a patient is not enough to sufficiently address the situation. Contraband can be placed inside the fence at any time due to the openness of the current fencing system, not just during recreation or fresh air breaks.
R4
Page 107

R4. SYBH needs to address the serious issue of AWOL from the PHF unit by means of the chain link fence recreation area. One option is to remove the chain link fence and replace it with concrete block. This would address the risk of AWOL, reduce the risk of contraband, and create a more welcoming and inviting recreation area for those on the PHF unit.
R5
Page 107

R5. SYBH has identified a replacement Video Monitoring system and submitted its request. This system plays a key role in the facility’s security, safety, and sense of well- being for both patients and staff. SYBH and the County need to recognize the importance of this system and prioritize funding by July 31st, 2022.
R6
Page 107

R6. SYBH needs to re-evaluate where contracted security services are located on the grounds and the scope of services provided.
R7
Page 107

R7. SYBH needs to update Policy and Procedure of recording of AWOL and related Hazard/Incident Report. The system should include:
R8
Page 107

Digitally date/time stamped signatures of any personnel that needs to be included of AWOL and Hazard/Incident Report
R9
Page 107

SYBH should consider a specific time frame for when each personnel needs to sign, review and finalize the AWOL report, no more than 7 days is recommended.
R10
Page 107

The system should include an “addendum” form, including a digital time/date stamp, if additional information about the AWOL has occurred from the original document time frame.
R11
Page 107

R8. SYBH and the County need to add to and or replace the facilities exterior building, site and street signage that has appropriate names and lighting. 97
R12
Page 108

R9. SYBH and the County need to address the importance of ensuring the comfort of patients in need of isolation and possible restraint. SYBH needs to identify and submit a replacement request to the County. The County in turn needs to recognize the importance by prioritizing funding by July 31st, 2022.
R13
Page 108

R10. SYBH and the County need to prioritize the performance of the work needed to complete the parking lot by September 30st, 2022. If funding is still not available, an allocation of funds needs to take priority to ensure this work gets completed.
R14
Page 108

R11. SYBH and the County need to take the initiative to clean up, enhance, and consistently maintain the overall appearance of the SYBH facility.
R15
Page 108

R12. SYBH and HHS need to reevaluate the scope and value of their training program, as well as their outside 3rd party consultant contract(s) to make sure it is being used effectively.
R16
Page 108

R13. SYBH needs to provide proper training and education to ensure sufficient knowledge / understanding of MHSA and Realignment funding in order to maximize the necessary funding required in order to support the county programs dependent upon this funding.
R17
Page 108

R14. SYBH and HHS need to assess its current staff, training and processes related to its budget. They then need to develop standardized processes/procedures to facilitate necessary communication between department heads and key fiscal personnel as it relates to internal reporting, discussion, and evaluation of ongoing budgetary goals and or issues, etc.
R18
Page 108

R15. There should be regularly scheduled meetings between Department Heads, Branch Directors, Administrators, and key fiscal staff. For transparency purposes, these meeting updates should be presented to the Sutter Yuba Behavioral Health Advisory Committee as well as Sutter County Board of Supervisor Meetings.
R19
Page 108

R16. Based on the grand jury’s research, a new Electronic Health Care Record System has been defined and budgeted by SYBH. SYBH needs an implementation plan. The County needs to prioritize and approve funding for a complete EHR for outpatient, inpatient, and PES.
R20
Page 108

R17. The County needs to work with HHS to perform a needs assessment and begin developing a long-term strategy to address the clear need for a new facility for SYBH which includes housing the PHF Unit. 98