Carol Jason had been a patient of BHC Fairfax Hospital for just minutes when she began rethinking the decision to check herself in to the psychiatric hospital.


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It was a Thursday evening in the spring of 2017, and Jason, a former elected official in Marysville, had come to Fairfax with contractions in her arms and legs that she worried might stem from a mental disorder. Though she had attempted suicide two months before, she told staffers at the hospital in Kirkland that she wasn’t feeling suicidal. The married mother of two was looking forward to celebrating her 54th birthday that weekend, and had scheduled an appointment with her psychologist the next Monday.

By the time she was admitted, the jerking in her limbs had subsided and she suspected it might have been an allergic reaction — not a mood disorder. Jason decided to exercise her right to leave. Instead of letting her go, Fairfax started the process to involuntarily commit her.

For Jason and other patients who check in voluntarily, the revelation that they can’t leave when they want to has shaken their faith in a system they turned to for help. The reasons for holding such patients vary, but the practice of doing so — sometimes for days — is a regular occurrence at some of Washington state’s private psychiatric hospitals, an investigation by The Seattle Times has found.


The question of discharging patients from a psychiatric hospital is exceedingly fraught. Doctors are only supposed to admit patients with serious mental-health conditions, and have to balance patients’ right to leave against concerns about their welfare. Washington is one of just a few states where patients who check in to a hospital must be “released immediately” upon their request, with no additional time for observation, according to state law. Yet many patients don’t realize that even if they check in voluntarily, a hospital can legally hold them against their will.

To do so, a hospital physician or nurse has to conclude that the patient poses an immediate danger and then initiate involuntary-commitment proceedings. In Washington state, this begins with a call to county government, which then sends a mental-health professional to evaluate the patient. The county evaluator can involuntarily commit patients for up to 72 hours before patients can make their case to a judge.

Fairfax, the state’s largest private psychiatric hospital, with 157 beds, routinely has held patients by claiming they wouldn’t be safe if released, only to be contradicted by government evaluators who find no grounds for committing them. At Smokey Point Behavioral Hospital in Snohomish County, nurses were told to notify the hospital’s chief executive any time a patient asked to leave early, internal records show, and several patients have complained that staff delayed their release or tried to intimidate them into staying.

The Times, in a first-of-its-kind analysis, examined what happened each time a health facility in King County requested an involuntary-commitment evaluation since 2015.

In more than 20,000 evaluation requests over four years, county officials usually agreed with the hospitals making the request, committing the patient 65% of the time.

But at Fairfax and Cascade Behavioral Hospital, the county’s two for-profit psychiatric hospitals, the trend was the opposite. In 220 requests by Cascade Behavioral, the county committed patients 31% of the time. In more than 750 requests by Fairfax, county evaluators agreed 32% of the time.

Last year, officials declined to commit three out of every four patients Fairfax held for an evaluation.


When patients at Fairfax and Cascade ask to leave before the hospital wants to release them, physicians “have a habit of calling” the county “to bless it to let someone go,” said Diane Swanberg, King County’s coordinator for involuntary commitment.

There’s no way of knowing how many patients drop their requests to leave after being told they could be involuntarily committed. Patients who proactively seek out help and are held involuntarily — or who feel coerced into staying — might be less likely to seek treatment in the future, some psychiatrists say. If they are committed, they can be held for three days before they get a hearing in court — and potentially much longer. In Washington state, an involuntary commitment on record also can increase a person’s chances of being committed in subsequent evaluations.

Fairfax is owned by Universal Health Services (UHS), one of the nation’s largest purveyors of mental-health care, with 188 inpatient facilities. The company has expanded rapidly in Washington state, adding psychiatric hospitals in Everett, Monroe and Spokane since 2014. It is building an 85-bed psychiatric hospital in Lacey in partnership with Providence Health & Services, and recently won approval to double the size of its Everett hospital to 60 beds.

UHS has been under investigation by the U.S. Department of Justice for a range of issues, including “admission eligibility, discharge decisions, length of stay and patient care issues,” securities filings show. The company disclosed in July that it will pay $127 million to settle DOJ’s civil investigation, and that a related criminal inquiry had been closed. It has denied wrongdoing.

In written responses to The Times, Fairfax said it holds patients for clinical and not business reasons, adding that patients’ average length of stay there is comparable to psychiatric hospitals nationally.


“Fairfax Behavioral Health is obligated to ensure the safety of patients and the community,” Beckie Shauinger, the hospital’s chief executive, said in a statement. “It is not uncommon in the mental health field for one professional to disagree with the assessment of another,” she said.

As for the state law that requires patients to be released immediately upon request, Shauinger wrote, it “is not an unqualified statement that literally means patients are immediately discharged.” She offered no legal basis for this interpretation but said the hospital needs time to evaluate patients and prepare a safe discharge plan. “Any ‘delay’ between a patient’s request for discharge and assessment,” she added, “is not for financial purposes but solely in the interests of the patient and in conformity with the law.”

“Fairfax Behavioral Health is obligated to ensure the safety of patients and the community. It is not uncommon in the mental health field for one professional to disagree with the assessment of another.” — Beckie Shauinger, CEO of Fairfax Behavioral

Several current and former Fairfax employees, speaking on condition of anonymity to discuss internal hospital matters, said that a patient’s insurance coverage regularly would come up in treatment-team meetings to determine when a patient would leave. But the staffers said they weren’t pressured to hold patients longer than they thought necessary.

A medical professional who worked at Fairfax said that the hospital would call for an involuntary- commitment evaluation for the majority of patients asking for an unplanned discharge, but added there was no direct pressure from the hospital’s management to do so. At Smokey Point, however, executives would yell at hospital staffers if they released patients whose insurance had authorized a longer stay, according to the medical professional who has also worked there.

“‘How come you let this person go?'” the former employee remembers being asked by executives and billing personnel at Smokey Point.

Richard Kresch, chief executive of US HealthVest, which operates Smokey Point, said “protecting patient rights is central to us” and denied patients are held for any reasons other than clinical ones.


“Patients are never held beyond the clinical team’s recommended discharge date,” he said in a statement. “Insurance companies and other payers routinely deny payment for patients when care is necessary. As part of our mission, we provide care to all patients regardless of ability to pay.  If our clinical team determines that a patient can benefit from additional treatment, we will offer care to the patient without any reimbursement.”

“Patients are never held beyond the clinical team’s recommended discharge date. Insurance companies and other payers routinely deny payment for patients when care is necessary. As part of our mission, we provide care to all patients regardless of ability to pay.” — Richard Kresch, CEO of US HealthVest

Michael Uradnik, chief executive of Cascade Behavioral, said that, “Due to the uniquely severe acuity of many Cascade patients, our clinicians generally err on the side of caution when making involuntary- commitment recommendations,” adding that releasing a patient too soon can increase the risk of suicide. He said that the Tukwila hospital “rejects any allegation that our physicians’ recommendations are based on anything other than good faith, clinically based findings.”

It isn’t only private psychiatric hospitals where patients run into resistance when asking to leave. In May, Suzanne Bolwell said she checked herself into Northwest Hospital, operated by UW Medicine, to treat her severe depression. The locked psychiatric unit where she was admitted was dirty, she said, with patients who were out of control. When she asked to leave, a doctor told her that he would try to have her involuntarily committed unless she agreed to stay.

“I was frightened, so I kind of gave in,” said Bolwell, 71, who retired after more than 40 years as a registered nurse. She said she was never informed of her discharge rights. She stayed for about two weeks.

A UW spokeswoman declined to comment on specific patient cases but said, “our policy is to provide our patients and their families with information on their rights and we let them know if we have any concerns about their medical or psychological condition.”

Carol Jason had initially sought help at Providence Regional Medical Center in Everett, before she was referred to Fairfax later that day. A Providence doctor had concluded that Jason wasn’t suicidal, writing “discharge home is reasonable” if there were no psychiatric beds available.


Staff at Fairfax, however, cited concerns about her “mood instability and impulsivity,” as well as her two suicide attempts since 2015, according to her medical records.

Jason recalls a doctor telling her, with a smile, that she could be committed if she insisted on leaving. “That is a risk you will take,” she remembers the doctor saying.


“The scariest and most expensive hotel stay”

Vickie Mulvany checked herself in to the Smokey Point Behavioral Hospital in January 2018, looking for a safe place to focus on herself.

The 48-year-old homemaker had been caring for one daughter with chronic migraines when her other daughter was badly injured in a river accident. She felt overwhelmed. One day while driving home along a two-lane road in Snohomish County, Mulvany’s focus narrowed to the shiny grille of a logging truck approaching in the opposite direction.

It “almost felt like it was just opening its arms to me, like just six inches over the line and it’s, it’s over,” she later recalled. “You don’t have to go home. It stops.”

Mulvany decided to seek out help. Her insurance company authorized a four-day stay at Smokey Point, where she was admitted for depression with suicidal thoughts.

Soon after she passed through the locking doors, Mulvany wanted out. Through the windows of a “quiet room,” she watched as a patient, a big man, shouted and pushed another patient up against the wall of a common room.


Each effort by staff to placate the aggressive patient gave way to another burst of profanity-laced demands — to turn off the television, to turn it back on. Then the man walked up to the room where Mulvany sat writing, and he pounded on the windows.

“I realized there’s one door in and out of this room,” she said in an interview. “It scared me to death.”

Mulvany asked to be discharged. The staff member she spoke with said she was new and didn’t know the procedure.

The next morning, Mulvany was so groggy from the medications she’d been given that she only wanted to go back to sleep. Still, she roused herself to ask how her discharge was progressing. This time, too, a nurse said she was new and didn’t know how the process worked. Another staffer said she would send along a form to fill out, but it never came.

“I realized there’s one door in and out of this room. It scared me to death.” — Vickie Mulvany, former Smokey Point patient

On Mulvany’s third day at Smokey Point, she was called into a room to meet with a nurse practitioner. She’d spent the previous night reading the hospital’s policy handbook, and pointed out that patients must receive a psychiatric evaluation within 24 hours. The hospital had failed to meet its own standards, Mulvany recalled saying. She demanded to be discharged.


The nurse practitioner agreed to discharge Mulvany, writing that she had made “good progress,” according to her medical records.

Mulvany tried to stay calm as she walked through each set of doors, terrified someone would stop her. When a staffer returned her boots, she didn’t pause to put them on. She walked in her socks out of the building into the cold February air.

Of the 50 hours she had spent there, she attended only two 30-minute group sessions, spending the other 49 hours eating, sleeping or passing the time. Smokey Point charged $6,000 for two days of “Adult Psych R&B,” according to her bill, with insurance covering a little more than half.

“It was literally listed as room and board,” Mulvany said. “And all I could think was it was the scariest and most expensive hotel stay I’ve ever had.”


What Mulvany didn’t know was that a case like hers — a voluntary patient asking to be discharged with additional days authorized by private insurance — caused acute anxiety for the hospital’s executives, according to internal records and former employees. It signaled that the patient was not responding well to treatment, raised liability concerns and meant the hospital was at risk of leaving money on the table.

The month before Mulvany arrived, John Beall, then Smokey Point’s chief nursing officer, sent an email to his staff with the subject line “AMAs,” an abbreviation for voluntary patients who ask to leave against medical advice. He instructed staffers to notify the hospital’s chief executive at the time, Matt Crockett, as soon as they received such a request, according to the email reviewed by The Times.


Beall declined to comment. Crockett didn’t respond to repeated requests for comment.

Twice a day, Smokey Point would send a list of patients scheduled for discharge to US HealthVest executives, who would demand explanations for additional, unplanned discharges, according to former employees. The reason for such close monitoring, the former employees said, was financial.

“They would say safety, but it was money,” said Lejla Marusic, a former manager at Smokey Point whose job was negotiating with insurance companies. Marusic resigned in May 2018, disillusioned with hospital executives’ approach to patient care.

“They would say safety, but it was money.” — Lejla Marusic, a former manager at Smokey Point whose job was negotiating with insurance companies

Kresch, US HealthVest’s CEO, said that the discharge calendar “is a clinical tool developed by the treatment team in order to provide sufficient time for follow up care scheduling,” adding that patients are treated regardless of their ability to pay and never held longer than clinically necessary.

It isn’t clear how often Smokey Point asks for its patients to be evaluated for involuntary commitment, as Snohomish County doesn’t track requests by facility. One patient told The Times she appreciated  that hospital staff made sure she was ready to leave before discharging her. Yet several other Smokey Point patients or their families have complained to the Department of Health or The Times that staffers tried to intimidate them into staying.

One of them, a young transgender man, said he overheard nurses refer to him as “it” when he arrived last September and was later pushed to attend women-only group therapy. When the patient told hospital staff his mother was coming to get him, they told him it wouldn’t be that easy.


“I felt intimidated by one of the nurses as he threatened that my insurance wouldn’t pay for anything” if he left against medical advice, the patient wrote in a complaint to the Department of Health.

The patient’s mother, a nurse manager, called Smokey Point 47 times over a couple days but never received a call back, she told The Times. She made the four-hour drive from their home in Southwest Washington and spent hours waiting in the hospital’s lobby.

Inside, a counselor told the patient that there was no record of his request to leave and that “she had no idea how to file an AMA discharge,” he wrote in the complaint. A nurse practitioner informed him that the hospital would start the process to involuntarily commit him if he insisted on leaving. Two crisis counselors tried persuading him to stay another day. Finally, to his bafflement, a nurse told him he could go.

“That whole experience was everything I feared about going to inpatient,” he said in an interview.

“That whole experience was everything I feared about going to inpatient.” — Smokey Point patient

Other patients who asked to leave opted not to press the issue when they encountered pushback.

Monica Preder, a 38-year-old nurse with bipolar disorder, checked into Smokey Point in January 2018 for a medication adjustment. She was asking to leave by her third day, her medical records show. Then her agitation began to worsen, diagnosed as a bad reaction to an antipsychotic drug that Smokey Point had ordered for her. While staff had scored her as a “very low” suicide risk three days before, a physician assistant checked a box that she was a danger to herself and others.


One week into her stay, a nurse observed that Preder wanted to leave and was “tearful and scared due to misbehavior and loud voices from another male patient in the unit.”

On Preder’s 11th day, a nurse wrote that she again asked to leave. Preder “was redirected to ask provider in the morning.”

The next day, a nurse wrote that Preder “shows no observable evidence of altered thought process.” She wasn’t released that day, or the next, or the day after that. When Preder was discharged in February 2018, she had been at Smokey Point for 15 days.

Preder said her experience gave her an empathy for patients that led her to seek a new job: working as a psychiatric nurse.

“Immediate” release

Carol Jason served on the Marysville School Board for three years before her physical health forced her to step away in 2006.

A series of surgeries and complications brought her pain to an intensity that caused her emotional distress. Then, in January of 2017, she attempted suicide after a therapist she had gone to for years declined to see her. In the aftermath of this attempt, she found a new therapist and set regular appointments. By late March, she was experiencing physical ticks that scared her.


Worried that her mental distress was causing the physical symptoms, Jason went to the emergency room on March 23, 2017, hoping a doctor could explain the reaction and prescribe a medication to neutralize it. She asked to be referred to Overlake Hospital, where she had previously spent time in the psychiatric wing. A hospital social worker said Overlake had no beds available, but Fairfax did.

When she arrived, Jason signed a series of forms consenting to be treated and received a document listing patient rights. On the second page, bullet point No. 34 of 58 stated that voluntary patients have the right to be released “unless involuntary commitment proceedings are initiated.”

Jason, like many patients in a state of distress, didn’t grasp the implications of these forms when she signed them. But she discovered their effect soon after.

As Jason was led to her room, she noticed that the bedding was rumpled, as if it hadn’t been changed since the last patient to sleep on it. There was food on the floor, she later wrote in a grievance to the hospital. The toilet had a blackish substance on the back of the seat.

Jason “expressed dissatisfaction with this hospitalization and immediately requested discharge,” a Fairfax doctor wrote in her record. Though she denied any suicidal or homicidal thoughts, she wasn’t allowed to leave.

That night, she laid down on top of the blanket on her bed and fell into a fitful sleep, waking to the screams of another patient in the ward.


Fairfax would not comment on Jason’s case “other than to state that we dispute the facts as presented by the patient.”

Under state law, patients like Carol Jason who check in voluntarily “shall be released immediately” upon request. This law, passed in the mid-1970s, puts Washington at odds with a majority of states that allow for some period of time, often 72 hours, to hold voluntary patients — without involuntarily committing them — for observation or while they make discharge plans, according to a 2014 paper published by the Harvard Review of Psychiatry.

There was only one way Fairfax could hold Jason: by initiating the involuntary-commitment process. And it could only take this step by concluding that Jason was likely to seriously injure herself or others at any moment, or that her mind had deteriorated to such a degree that she couldn’t provide for her own safety.

While hospitals have the option to seek involuntary commitments, their primary duty — “arguably the only duty” — to voluntary patients asking to leave is to release them, a state appellate court ruled in 2013 in a case involving a patient who died in a car crash soon after leaving a psychiatric unit. To be held liable for releasing such a patient, a hospital and its staffers would have to be found grossly negligent, a high legal standard for failure to exercise even a slight amount of care.

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Washington state’s deference to patient rights could trigger an unintended consequence, some experts said. Psychiatrists might feel more pressure to request an involuntary evaluation in Washington, where they have no other option to hold a patient asking to leave, said Amir Garakani, director of education at Silver Hill Hospital in Connecticut and lead author of the Harvard paper.

“By having an ‘immediate discharge’ requirement, providers have to choose between the risk of discharging a potentially unstable or unsafe patient,” he said, or “holding a patient against their will, thereby infringing on their rights.”


It’s not clear how frequently hospitals fail to act immediately on a patient’s request to leave. Fairfax said in a statement that it starts the discharge process as soon as a patient asks to be released. Yet when Carol Jason asked to leave shortly after checking in at 8:30 p.m., the hospital didn’t call King County’s 24-hour commitment line to request an evaluation until the next afternoon, about 17 hours later, county records show.

The evening before the call, a nurse had written that Jason appeared “anxious and irritable” but was otherwise cooperative.

The county mental-health worker who took the call the next day got a somewhat different assessment. Jason was being “verbally aggressive with staff” and had said “I’m about to get violent” if she wasn’t discharged, according to county records of the call.

Jason denies saying this, and she questions the accuracy of Fairfax’s records. One nurse’s note refers to Jason with the pronoun “he” three times. Another note in her record describes a patient with masculine pronouns and as “being homeless.” Jason and her husband have owned their house in Marysville since 2001.

“I am a ‘she’ and I have never been homeless,” she said.

Jason isn’t alone in complaining about unreliable documentation at Fairfax. In one case, two weeks before she arrived, Fairfax had sought to extend the involuntary commitment of a patient whose records stated “patient needs to be discharged” and “this is not an appropriate setting for the patient,” according to a Snohomish County official’s complaint to regulators.


After a separate court hearing the next month, a Snohomish County official emailed Fairfax executives that “the question argued by both sides was the reliability and credibility of your records.”

King County received Fairfax’s request to evaluate Jason at 1:46 p.m. on Friday, March 24. Had the request come from a hospital’s emergency room, the county would have had to arrive within six hours, according to state law. But because the request came from a hospital where Jason had been admitted, the deadline wasn’t until the next court day, which excludes weekends.

A request on Friday meant the county had until Monday to commit Jason or release her.

Evaluation and aftermath

Fairfax’s own psychiatric assessment of Jason, conducted the same day it requested an involuntary evaluation, didn’t suggest a patient in crisis.

“Thought content is appropriate without any sign of hallucinations, delusions or paranoia,” a physician assistant wrote. “Patient’s judgment is good,” the evaluation states. “Patient’s suicide risk is low.”

This didn’t mean that Jason was free to go. “As she has requested discharge, she will be seen by the DMHP” — short for “designated mental-health professional,” a county official — “for an opinion as to her suicide risk,” the evaluation concluded.

As Jason insisted on her right to leave, a physician tied her demand to a symptom of mental illness. “She is grandiose — feels she should be able to sign out right after she was admitted,” the physician wrote.

As Jason insisted on her right to leave, a physician tied her demand to a symptom of mental illness. “She is grandiose — feels she should be able to sign out right after she was admitted,” the physician wrote.

Jason was scared by the angry outbursts of other patients and felt her post-traumatic stress disorder spike. A staff member brought her to an empty room for her to be alone, and she sat down on the bed and sobbed. “This act of kindness gave me the strength to endure my time at Fairfax,” she later said.

King County had until Monday to evaluate Jason. But at 11:25 p.m. that Saturday night, a county official contacted Fairfax to examine her. Fairfax said Jason was asleep and asked the official to come when she was awake, county records show. Jason was never told.

Shortly after midnight on Monday morning, Jason was awakened by Fairfax staff. A mental-health official for the county had arrived to evaluate her for involuntary commitment.

Jason admitted to the official that she had been “difficult” with hospital staff. Yes, she said, she’d attempted suicide two months earlier. She seemed agitated and spoke rapidly, the official observed, but this also seemed consistent with her frustration that Fairfax wouldn’t let her leave.

It was 2:25 a.m. when the official concluded his evaluation.

Jason denied any suicidal thoughts, he noted. She had family support and a scheduled appointment with a therapist. “She is not presenting with safety concerns,” he wrote. He had no grounds to commit her.

It had been three days since Jason asked to leave. Fairfax billed $11,200 for her stay, receiving a $4,100 payment from Jason’s insurance.

It had been three days since Jason asked to leave. Fairfax billed $11,200 for her stay, receiving a $4,100 payment from Jason’s insurance.

Soon after leaving, Jason lodged a complaint with Fairfax. The hospital apologized for the “unfortunate experience that you had” but contended it was within its rights to hold her.

Jason, after researching state law, believes Fairfax held her illegally. She filed complaints with the Washington state Department of Health, the Medical Commission, the Nursing Commission, The Joint Commission, the U.S. Department of Health and Human Services and the Washington state Attorney General’s Office. Each declined to investigate or impose any penalty.

Jason has long been a believer in seeking out help, but her experience at Fairfax has shaken her faith in the system. “I would think twice about getting help because of this,” she said.

Vickie Mulvany, the former Smokey Point patient, has struggled with the same question. In March, a little more than a year after her stay, she again found herself in severe depression.

“For the first time, I feel like I have no options as I realize I will never go back to a behavioral health facility,” she told the Times. Instead, she gazes at four words she had inked into her forearm after her experience at Smokey Point: “I made a promise.”

“For the first time, I feel like I have no options as I realize I will never go back to a behavioral health facility.” — Vickie Mulvany, former Smokey Point patient

Mulvany made the promise to her daughters: To never try to kill herself. To seek help from friends, family and a helpline. To turn to her own personal support network.

“There are days I glance at those words and take comfort in them, and days I stare at them and feel trapped,” she said. “Whatever their hold on me, they keep my head above water. They keep me alive.”


Daniel Gilbert:; Twitter: @ByDanielGilbert


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