Staff members and some patients said Singh's focus on documentation — aimed at proving compliance with the consent judgment — came at the expense of patients' well-being.
Monthly treatment plans grew to exceed 30 pages per patient, much of it redundant and clinically useless, current and former staffers said. Highly paid psychotherapists and other staffers were diverted from treating patients to audit and polish patient records for review by a federal court monitor.
With about 300 new forms to fill out systemwide, staff members said they no longer had time to play cards and chat with patients, activities that helped build connections and head off violence.
Patients said they missed the attention.
"Psych techs don't have time to be psych techs," said Philip Zullo, 34, who spent eight years in state hospitals after threatening an ex-girlfriend. Speaking of the system's frontline staffers, he added: "They're irritated by the time they have finished with the paperwork."
The goal seemed to be technical compliance above all else, staffers said. At Patton, the hospital administrator told hospital police investigators in late 2009 to focus on patient abuse complaints for the six months that were subject to review by the court monitor's team and shelve the older ones, according to a letter to the monitor from a former lead investigator.
It's "pure smoke and mirrors," wrote former investigator John Olive.
Even participation in the treatment mall was not what it seemed, staffers said. When charts showed that almost all patients were falling short of the required 20 hours a week of classes, the state lowered the bar — twice — so patients were considered noncompliant only if they didn't make it to a single class in a month.
Participation soared — at least on paper.
A family bereft
Diane Rodrigues arrived at Metropolitan State Hospital in September 2009. The former kindergarten teacher had grown up in a close-knit San Jose family with six siblings. She was diagnosed with schizophrenia in 1985 at 28, but had emerged from many crises to water-ski and paint once more, said her twin sister, Debbie Coughlin.
Still, her illness worsened.
In November 2009, she repeatedly somersaulted off her bed at Metropolitan in response to voices, according to an incident report. A staff member was assigned to watch her at all times.
Two days later, she began to flip off the bed again and was given Benadryl, an over-the-counter antihistamine and sedative. Soon she flipped again. Approached by a staffer, she asked to stay on the floor and rest. It was hours before anyone realized her neck was broken and she was paralyzed. She died in May 2010 of related causes.
"We trusted she was going to a facility that could manage someone with this severe of an illness," Coughlin said. "Could she not have been medicated?"
Documents reviewed by The Times show that staff members did not add anything to Rodrigues' usual medication other than Benadryl. She was not placed in physical restraints.
In general, mental health administrators at the hospitals pressed staff members to limit use of emergency calming medication, multi-drug cocktails and other similar measures, interviews and documents show.
Although clinicians generally supported non-coercive measures, they said higher-ups without medical training second-guessed the use of restraints, seclusion and medication even when they were necessary.
"The paperwork and number of hoops you have to jump through and the backlash after the fact makes it virtually impossible" to use these measures, said Dae Peter Lee, a Metropolitan psychologist. "You'll get called into meetings, 'Why didn't you do this? Why didn't you do that?'"
Metropolitan's former executive director, Sharon Smith Nevins, whose background is in social work, told clinicians to release patients from restraints and remove them from one-to-one observation in most cases, said several current and former staffers.
Smith Nevins denied trying to influence treatment. "I encourage clinicians to exercise clinical judgment since the application of restraints as well as ordering of one-to-one observation is based on a clinical decision," she said in a statement. She abruptly left her state job in December.
In a May 2010 letter to Metropolitan staff, Radavsky, then the state's deputy director of long-term care, noted approvingly that "by the end of 2009, seclusion events were nearly eliminated there and restraint events were down by 94%."
But in an interview, Radavsky said staff members "were never told to sacrifice safety or security."
Asked about Rodrigues' death, she said that the department investigated but that the findings were confidential.
A January 2011 internal report acknowledged that Metropolitan staffers had frequently been reluctant to use restrictive practices, even when necessary. The report suggested that clinicians had misinterpreted the directives of superiors.