Strapped down: Psychiatric patients are restrained at sky-high rates at this L.A. hospital

L.A. General’s inpatient psychiatric unit has restrained patients at a higher rate than in any other in California, a Times analysis has found.

When he came home from the hospital, Marcelus Laidler began to wet the bed. His mother noticed he seemed leery, questioning everything she did.

His ankles and wrists bore scars — the result, he said, of repeatedly being strapped to a bed with restraints at Los Angeles General Medical Center.

“I have nightmares I’m being restrained,” said Laidler, who has schizophrenia and bipolar disorder. “That hospital is like one bad dream after another.”

Hospitals are forbidden under federal law from restraining psychiatric patients except to prevent them from harming themselves or others. Restraints can be used only when other steps have failed and are widely discouraged by psychiatric professionals, seen as a measure of last resort that frays trust and can traumatize patients.

At L.A. General — a public hospital serving some of the poorest and most vulnerable people in the nation’s most populous county — the psychiatric inpatient unit has restrained patients at a higher rate than in any other in California, a Times analysis has found.

Federal records show that over a recent four-year period, L.A. General’s Augustus F. Hawkins Mental Health Center has reported a restraint rate more than 50 times higher than the national average for inpatient psychiatric facilities, ranking it among the highest in the country.

Those numbers doubled between 2020 and 2021 — the latest figures publicly available — even as the statewide average for other inpatient facilities barely increased.

L.A. General staff have reported 200 cases in which psychiatric inpatients were restrained for a total of 24 hours or more within a month, records dating from 2018 show. Nearly 40 of them were restrained for the equivalent of one week or more, including a woman who spent an entire month in restraints.

Patients are always restrained when transported between the Hawkins psychiatric unit in South L.A. and the hospital’s main Boyle Heights campus, a drive of more than 15 miles, according to county officials. Hundreds of such trips happen each year. County health officials said the restraints are necessary to prevent patients from jumping out of moving vehicles or assaulting staff.

Some psychiatric care experts decried the blanket practice for not distinguishing between patients who might be dangerous and those who aren’t. Even accounting for those transit hours, the restraint rate at L.A. General far exceeded the national average in recent years.

L.A. General officials said they turn to restraints as a “last resort intervention” for combative patients in the face of roughly two dozen physical assaults annually on Hawkins staff. A handful of extremely violent patients has inflated its restraint rate, hospital officials said.

L.A. County officials said that the hospital has received more patients with violent criminal histories in recent years and that Hawkins has “become a sort of pseudo psychiatric jail ward.” Exacerbating the problem, they argued, are long waits for patients who should be transferred to state hospitals or other facilities for longer-term care but instead remain at L.A. General.

“We have not been prepared to handle people at this level of violence,” said Dr. Brad Spellberg, L.A. General's chief medical officer. He added: “This is about a population of people who have a preexisting history of repeated felony-level assaults who are overtly telling you, ‘I’m going to kill you.’”

When hospital leaders have asked doctors and nurses about trying to reduce the use of restraints, they respond, "You can’t not restrain these folks,” he said.

“If you put these patients in our hospital,” he said, “they end up in restraints.”

Spellberg and other county officials argued that L.A. General cannot be fairly ranked against other hospitals because of its unique challenges as a safety net hospital close to Skid Row and correctional facilities. Private psychiatric facilities are unwilling to take the “difficult” patients that it handles, according to the county Department of Health Services, which operates the hospital.

In reaction to concerns raised by outside experts, Spellberg said, "You come walk a beat in the hospital and take care of the 250-pound person with personality disorder and psychosis who has violently assaulted a dozen people and is telling you they're going to murder and rape you, and say, 'Yeah, you don't need to restrain that person.'"

The county declined a Times request to observe the psychiatric unit, saying it could not accommodate a visit without violating patient privacy. Hospital officials said government regulators had consistently found restraint use at Hawkins to be in line with state and federal rules.

Mental health experts challenged the explanations put forward by Spellberg and other county officials.

“I know those populations and I know how challenging they are,” said Dr. Roderick Shaner, former medical director of the county’s Department of Mental Health, who worked to reduce the use of restraints in psychiatric facilities before his retirement in 2018. "I don’t think that you can say that the 'nature of the population we are treating ... justifies restraints.' It justifies the need for sophisticated management of behavior, but restraints are not the go-to thing.”

Other large safety net facilities in California and across the country do not use physical restraint at anywhere near the same rates as L.A. General, formerly known as L.A. County-USC Medical Center.

L.A. General psychiatric inpatients were restrained at a rate 10 times higher than at Zuckerberg San Francisco General Hospital, according to The Times' analysis of data from 2018 to 2021, the most recent year available.

Its restraint rate was also far higher than the two other L.A. County-run hospitals with inpatient psychiatric units — 14 times higher than Olive View-UCLA Medical Center and seven times higher than Harbor-UCLA Medical Center.

"It doesn’t make sense to me that patients in L.A. are more seriously psychotic and dangerous than patients at a general hospital in San Francisco," said USC law professor Elyn Saks, who has studied the use of restraints for decades.

Spellberg said the medical facility most similar to L.A. General would be Bellevue hospital in Manhattan, a public safety net facility. The Times analysis found that L.A. General has restrained psychiatric patients at a rate 23 times higher than the New York hospital's inpatient unit over the same period.

Hospitals restrain patients in a range of ways, some more restrictive than others. Medical staff may strap down their arms and legs to a bed; in other cases they tie the wrists and ankles of a patient so that they can still walk. L.A. General declined to provide the specific manufacturers and models of physical restraints used there, saying that the misuse of such information could threaten safety.

Although hospitals such as L.A. General are required to report how often they use restraints on psychiatric patients, high rates do not automatically trigger action from federal or California hospital oversight agencies, The Times found.

And the required reporting does not give a full picture of restraint use: The federal restraint data measure only what happens to patients who have been admitted to inpatient psychiatric units, such as Hawkins. When psychiatric patients admitted to other units in the hospital are restrained, those incidents are not included in the federal data.

L.A. County officials are legally restricted from sharing details about specific patients, and hospital records are confidential under federal law.

The Times obtained thousands of pages of medical records for two patients who underwent long periods of restraint in recent years at L.A. General. Both were treated in the same unit outside the hospital's locked psychiatric ward.

One died days after she had been strapped to a bed, spending 36 hours in restraints in less than a week. Last year, the county settled a lawsuit filed by her mother, who argued that the blood clots that killed her daughter were the consequence of long immobilization due to restraints and medication. 

The other patient, Laidler, was restrained for at least 300 hours over the course of five months — in many cases for behavior that experts told The Times did not justify restraint. 

When he needs to settle his mind, Laidler, 48, thinks about basketball.

It’s hard for him to remember a time when basketball wasn’t in his life. He loved the sport as a teen growing up in L.A. and dreamed of playing professionally.

Those plans took a turn after the death of his grandmother, which spurred a nervous breakdown that led to his diagnosis with schizophrenia and bipolar disorder at age 16, his mother said. Doctors also detected a brain tumor as big as a baseball, she said, which was removed on Valentine’s Day 1992.

More than two years ago, a psychiatric crisis had landed him at the inpatient ward at Hawkins when another medical issue led him to be transferred to the main campus of L.A. General, according to medical records reviewed by The Times. He was placed in a medical ward for treating patients displaying violent or harmful behavior who are also suffering illness or injury.

Early in his stay, nurses repeatedly noted he was cooperative and compliant with care, medical records show.

But several weeks after his arrival, he grew agitated one night and began shouting at the nurse station, demanding to speak to his doctor “or I will tear up the whole unit,” according to notes in his medical records.

When a doctor arrived hours later, after he had started shouting again, Laidler complained that he was treated like a “second class citizen,” according to the doctor’s notes. He began talking about “his past life as a police officer, a physician, and an airline pilot,” how he had been present at the Tulsa Race Massacre of 1921, and “how protective he is over his mother.”

“His thought process appeared unorganized and non-linear,” the physician wrote. “He then stated he would ‘kill everyone in the unit’ when he wakes up.”

When psychiatric patients make threats, nurses and doctors must gauge whether those are idle words or indications of an imminent attack, experts said.

The doctor did not indicate that Laidler had attempted to hit anyone. But hospital staff decided to restrain him, strapping down his arms and legs. Medical records said he was agitated, “not following simple directions” and not verbally affirming that he would not hurt himself or others.

Two days later, he was placed in restraints for about 12 hours after he was found shouting in a hallway, arguing with other patients and then calling staff members derogatory names. Once strapped to his bed again, the records say, he continued cursing, shouting, “I don’t care, I will kill you and your mama.”

In another instance, hospital staff wrote he had been restrained after throwing coffee on the floor, causing a staffer to slip and fall. He was "being aggressive with staff" and was unable to assure them he wouldn’t hurt himself or others, staff wrote. 

In an interview, Laidler and his mother said he didn’t spill the coffee on purpose, and he didn't recall threatening to kill people in the unit. He and his mother, Debra Legans, said the medical records did not reflect instances of threats and aggressive behavior from the staff toward him. Legans also felt that medical staff had misinterpreted his behavior, seeing ordinary actions as aggressive or disruptive.

Medical records said Laidler was repeatedly restrained for being "unable to follow instructions, unsafe."

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In one episode, a nurse wrote that he was “purposely spilling soda in the hallways” and walking around “intrusive towards other patients and their rooms,” according to medical records. Laidler persisted despite efforts to redirect him, so he was put into restraints, where he remained for 21 hours until he agreed not to threaten staff, a nurse wrote.

In that case and many others, the records show, doctors documented the restraints they ordered as “non-violent,” a designation meant for restraining patients who aren't being aggressive or self-destructive but might be pulling out their IV lines, breathing tubes or other necessary medical devices. 

https://www.latimes.com/california/story/2023-10-19/psychiatric-patients-restraint-high-rate-california-los-angeles-general-hospital (Pay to view, at LATIMES.com, not in person, not on the newsstand not on ABC 7 Eyewitness News, starring a misogynist or two, shall I say...? And please learn propriety, young girls and boys, please behave as dignified people, who respect the sanctity of human life, and not as murderers, who disregard God