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The Mental Health Project is a Seattle Times initiative focused on covering mental and behavioral health issues. It is funded by Ballmer Group, a national organization focused on economic mobility for children and families. The Seattle Times maintains editorial control over work produced by this team.

For a time, it seemed no one thought there was anything wrong with what happened to Carol Jason.

She checked herself in to BHC Fairfax Hospital in Kirkland in March 2017 and, disgusted by what she saw inside, promptly asked to leave the psychiatric facility.

Fairfax tried to have Jason involuntarily committed, even though a hospital assessment had found her judgment was good and risk of suicide low. The staff held her for four days against her will until a county official evaluated her — and found no grounds to commit her.

Jason, a 59-year-old former school board official in Marysville, felt this violated her right as a voluntary patient to leave when she wanted. But Washington state commissions that regulate doctors and nurses rejected her complaints. The state Department of Health told her “there is no apparent violation of hospital laws.” The U.S. Department of Health and Human Services said it would “resolve this matter informally” by providing Fairfax with “technical assistance.”

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Jason did not let it go. After her case was featured in a 2019 Seattle Times investigation of psychiatric hospitals holding voluntary patients against their will, she wrote a letter to Gov. Jay Inslee. DOH opened a new case and an investigator interviewed her in January 2020.  

This time, DOH cited Fairfax for trying to involuntarily commit Jason without sufficient reason, a violation that “can cause patient harm and trauma.” Before January 2020, DOH had never cited a psychiatric hospital for such a violation. It has since found that at least five hospitals held 17 voluntary patients when they should have been released, according to records reviewed by The Times.

Jason is now in her third year of a lawsuit against Fairfax, alleging the hospital wrongfully held her — a case that could shed new light on the obligation of hospitals to let patients leave.

When it comes to Washington’s mental health system, much of the public and legislative focus is on caring for the most severely ill who put themselves or others in danger. But many, if not most, people who seek inpatient mental health care do so voluntarily. When hospitals take away their right to leave, former patients say, their experience can shape how willing they are to proactively seek care in the future.

Most states allow hospitals some time to keep voluntary patients for observation before deciding whether to release them. Washington requires that adults who admit themselves to a hospital be “released immediately” upon their request — unless they present an imminent danger to themselves or others or are “gravely disabled.” The only way hospitals here can legally hold such patients is by persuading them to stay or by initiating the process to involuntarily commit them.

To hold patients against their will, hospitals call county officials known as designated crisis responders. Fairfax’s requests to King County for involuntary evaluations of patients plummeted by about 50% in the summer of 2019, coinciding with inquiries from The Times about the practice, and county data show they remained well below the previous level through the end of last year.

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Christopher West, chief executive of Fairfax Behavioral Health, said in a statement that any decrease in such requests is due to “enhanced procedures” that “streamline the process while ensuring the patient is still safe for discharge.” He added that the hospital “categorically denies any allegation or insinuation” that Fairfax requests involuntary commitment evaluations “to improperly extend patient stays,” saying they do so only to ensure patients are safe.

The Times investigation in 2019 “led DOH to look deeper into how hospitals were interpreting” the law, a department spokeswoman said. In April 2021, DOH warned hospitals that it was unacceptable to delay releasing voluntary patients for the “convenience or other interests of the facility,” and it “should take a matter of hours.” Still, the practice of hospitals trying to involuntarily commit patients who want to leave — and complaints about their tactics — have persisted.

Holding patients who ask to leave can bring in additional revenue for hospitals by prolonging their stay. Fairfax’s corporate parent, Universal Health Services — one of the largest mental health care providers in the nation — agreed to pay $117 million in 2020 to resolve claims by the U.S. Department of Justice that included failing to discharge patients who no longer required inpatient care and billing for “excessive lengths of stay.” The company denied the allegations and didn’t admit to wrongdoing.

Jason declined to comment, citing the pending litigation. Fairfax denies her claims.

Care or coercion?

Washington’s law makes it sound simple to leave a hospital, but in DOH inspection records, patients who ask to leave psychiatric hospitals face a series of hurdles.

The parents of an 18-year-old patient admitted to Rainier Springs in Vancouver, Clark County, were told she couldn’t be immediately released — but when an ombudsman contacted the facility’s director, the hospital was able to do so within 30 minutes, one inspection found.

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At South Sound Behavioral Hospital, in Lacey, a patient was initially told by one doctor she could leave but then her spouse was informed “corporate was denying release” without a second opinion, according to DOH records. “I wanted to go, but I felt trapped,” the patient said.

At Smokey Point Behavioral Hospital, in Marysville, parents of an adolescent admitted voluntarily for suicidal thoughts asked to take their child to another facility on the advice of a psychiatrist.

Smokey Point staff said the patient had attempted suicide while there and initiated the involuntary commitment process. Snohomish County sent a designated crisis responder, or DCR, who determined the patient’s safety wasn’t at risk and remembered the case well when contacted by DOH.

“I told [them] they were holding the patient hostage from [their] parents, that [they] did not in any way meet criteria to be involuntarily detained,” the county official said, according to DOH’s report. The official said the hospital’s practice is “shameful and borderline criminal. As long as the patient’s insurance will still pay, they will try to keep them and call for a DCR, hands down without question.”

DOH found that incident, and others, substantiated “a continued failure of the facility to immediately release voluntary patients upon request.”

Richard Kresch, chief executive of US HealthVest — which owns both Smokey Point and South Sound — said “the hospital disagrees with all the statements put forth” in written questions from The Times, but didn’t elaborate.

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Toni Long, chief executive of Rainier Springs, acknowledged the mandate to release voluntary patients immediately and expressed appreciation for DOH’s recent guidance. The hospital must assess each patient asking to leave, she said, and ensure there is a safety plan and follow-up care scheduled. “We work to do all of this as expeditiously, yet as safely, as possible,” Long said, adding, “we are dealing with life-and-death situations.”

Carol Jason goes to court

In 2008, attorney Chris Huck filed a lawsuit against Overlake Hospital, claiming it was negligent for discharging a patient without first having her evaluated for involuntary commitment. The patient, Sherri Poletti, died shortly after her discharge in a single-car accident.

An appellate court ruled against Poletti’s estate in 2013, concluding that “releasing a voluntarily admitted patient ‘immediately’ upon request is the primary duty, and arguably the only duty” of the hospital under the state’s Involuntary Treatment Act.

In March 2020, Huck sued Fairfax on Jason’s behalf, claiming that the hospital, a doctor and nurse practitioner violated her rights by “wrongfully confining” her. He was now effectively making the opposite case he had for Poletti. He was making the argument that had won. Huck declined to comment.

Jason had been referred to Fairfax after a trip to an emergency room for spasms in her arms and legs. Those symptoms subsided by the time she checked in, and Jason was appalled by the unsanitary conditions of the room she was shown. She asked to leave.

Fairfax staffers resisted. They noted that Jason had attempted suicide two months earlier, after a psychologist who had treated her for years abruptly declined to see her. (DOH cited the psychologist last year for violating professional conduct standards, including for failing to maintain boundaries and not adequately terminating his care of Jason.)

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The doctor, Sule Karakus, and the nurse practitioner, Mustapha Hydara, asked a judge to throw out Jason’s lawsuit in March 2021, arguing that they had no choice to but try to involuntarily commit her and no legal ability to discharge her until a DCR had evaluated her. Their attorneys didn’t respond to requests for comment.

Jason was “‘grandiose,’ as she felt like she should be able to sign out right after being admitted,” according to a motion for summary judgment by Karakus and Hydara.

“There is nothing ‘grandiose,’ ” Huck shot back, about Jason asking Fairfax staffers to “comply with their mandatory duty under the law.” Quoting at length from the Poletti case and others, Huck argued that there’s no evidence that Fairfax ever evaluated Jason to see if she met the criteria for involuntary commitment before trying to commit her.

Fairfax’s psychiatric assessment of Jason, dated the same day as it requested an involuntary evaluation, concluded that her “judgment is good” and “suicide risk is low.”

The judge denied the motion to throw out the lawsuit. “The Court finds that Defendants either misunderstood or willfully disregarded their obligation to release Plaintiff if clinically stable,” Judge Johanna Bender wrote last year.

In May, Huck filed an amended complaint with what he considered a “damning” revelation: DOH’s finding that Fairfax failed to release Jason even though she did not meet the threshold for involuntarily commitment.

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Fairfax denies Jason’s claims, saying it only held her as long as necessary and complied with the law. As for DOH’s finding that Jason didn’t meet the criteria for commitment, Fairfax lawyers called the record “inadmissible” and based on Jason’s “memories of what she thinks happened almost three years after her admission.”

The DOH record includes comments attributed to Fairfax’s risk manager that shed light on how the hospital considers the rights of voluntary patients.

“All patients admitted to the facility,” the manager said, meet the criteria to be involuntarily committed, “even voluntarily admitted patients.”

The manager told DOH investigators that staff “do not orally notify voluntary patients” of their right to be released immediately, despite a state law requiring this disclosure. If they did, he said, “Everybody would be asking to leave.”