Five elopements or walkouts of mentally ill patients from the Guam Behavioral Health and Wellness Center this year have been investigated, and prompted policy reforms at the center, officials said.

GBHWC Deputy Director James Cooper-Nurse told the Pacific Daily News that internal investigations and procedural reforms began after the second elopement, weeks before a disability watchdog’s July 9 public statement about the incidents.

Elopements occur when patients leave a psychiatric or health facility without permission or proper supervision, often due to a serious mental illness and/or diminished capacity to make safe decisions.

The five elopements triggered a public warning and “grave concerns” from the federally mandated watchdog Guam Legal Services Corporation–Disability Law Center, GLSC-DLC.

The watchdog accused the GBHWC of failing to prevent repeated incidents involving patients under 72-hour involuntary psychiatric holds over a lack of formal policies and oversight.

It said the GBHWC “has disregarded a pattern of repeated elopements and failed to address its practices that put the lives and safety of individuals who need help at risk and in harm’s way.”

Cooper-Nurse said GBHWC Director Carissa Pangelinan clarified the cases involved individuals under 72-hour involuntary psychiatric holds, and not general crisis stabilization patients.

“So actually, after that second incident, director had asked me to go ahead and convene our internal investigation, which I had done,” Cooper-Nurse said. “In the process of that internal investigation, we’ve already been identifying some of those areas that we need to improve and some of those areas where we need to either create new policy or modify existing policy.”

Guam’s federally mandated Protection and Advocacy agency for individuals with serious mental illness since 1999, the GLSC-DLC, said the five incidents involved patients previously assessed as dangerous to themselves or others or as gravely disabled.

It said the GBHWC lacked formal, written procedures for preventing or responding to elopements, failures that could result in injury or death.

“GBHWC practices and lack of preventive guidelines and action toward elopements should be unacceptable in our community of Guam,” the watchdog said.

Cooper-Nurse said the GBHWC is finalizing written policies and expects them to be ready for review by this week.

Dry-run drills are scheduled, he said, and the agency is coordinating with the Guam Police Department and other key partners to tighten safety protocols and improve intake and detention processes.

“The process itself is written already. Now it’s more about formatting and making sure that everyone’s trained on it,” he said.

Transition period

A procedural gap the GBHWC is addressing is the transition period between a patient’s arrival and formal admission, Cooper-Nurse said.

“Part of what we’re uncovering is a big sort of gap area is in the transition from when someone is bringing an individual to the department for an assessment for a 72-hour involuntary hold, and then actually them getting into the building,” Cooper-Nurse said.

He said some of the interim procedures have to do with “looking at shortening or reducing that transition time and also creating that safe, comfortable environment” not just for the GBHWC consumers, but for its staff and “whoever it is that’s bringing the individual in.”

Mobile crisis teams began community outreach in March, around the time the elopements occurred, Cooper-Nurse said.

He added that staff members are revisiting partner organizations to explain what the new procedures mean in practice.

Key partners include GPD, Guam Memorial Hospital, Guam Regional Medical City, U.S. Naval Hospital and private clinics.

“According to the law, anyone can petition for a 72-hour hold,” Cooper-Nurse said. “The biggest partners we see that are involved in escorting or bringing an individual here have been the police, GMH and GRMC.”

Despite public criticism from GLSC-DLC, the GBHWC has not received lawsuits, legal claims, or official liability notices related to this year’s elopements.

“We have not received any,” Cooper-Nurse said. “The complaints we’ve received, if it can be considered a complaint, is this discussion with Guam Legal Services. We consider Guam Legal Services a partner in this.”

Cooper-Nurse described the legal and ethical complexity involved in enforcing involuntary psychiatric holds while protecting civil liberties.

“What the 72-hour hold amounts to is our ability to take a person’s civil rights away and detain them involuntarily,” Cooper-Nurse said. “That doesn’t feel very safe for folks. The goal is always to reduce the amount of seclusion and restraint and to really offer as much as possible, caring, treating environment where people have a choice in their health care.”

When it came to patients who exhibit violent behavior or are unresponsive to care, he said they may meet the legal threshold of being “gravely disabled,” which qualifies them for involuntary detention.

“Those would fall into the gravely disabled category, which then they would…that is another sort of criteria that our provider [uses] to determine an involuntary hold,” Cooper-Nurse said.

He added that final admission decisions must be made by licensed mental health professionals following proper assessments.

“Our providers still need to assess them and determine that they meet that criteria to be involuntarily held,” Cooper-Nurse said. “That transition time… is the procedural piece that we need to shore up.”

Reducing stigma

As new protocols take effect and training continues, Cooper-Nurse said the center remains focused on building public trust and reducing stigma around behavioral health care.

“Part of our role is to de-stigmatize mental health and behavioral health,” he said. “This is a safe facility, and we really do want to ensure that there’s this de-stigmatized notion that coming to this building means you’re going to be detained. Yes, we have that ability in the most severe cases, but we also have a lot of voluntary health care services that people can [access].”

Sen. Chris Barnett also inquired with the GBHWC, and inquired whether legislative support is required to improve patient safety, secure additional resources or fortify the center’s compliance efforts.

“I am prepared to assist,” the senator said, adding that the purpose of the inquiry is not to assign fault “but to ensure that the public systems tasked with caring for our most vulnerable residents are operating within the bounds of applicable laws, federal program standards, and clinical best practices.”