It's too soon to say whether the story of James Flavy Coy Brown is an anomaly, as Nevada regulators claim, or if budget-stressed mental health service professionals are "dumping" disoriented, mentally ill people on the rest of the nation.

If one thing is certain, it's that a lot of people are now actively engaged in answering that question. Among them: at the Sacramento Bee, city attorney's offices in Los Angeles and San Francisco, the U.S. Centers for Medicare and Medicaid Services, and the commission that certifies hospitals in the United States.

Let's return to the beginning, to the story of a man who showed up at a Greyhound bus station in Sacramento on Feb. 12. Brown suffers from schizophrenia, which among other things makes it difficult for a person to think clearly. Fortunately for him, Brown was thinking clearly enough that morning to head toward a local police station and ask for help.

The story made it to the Sacramento Bee through Loaves & Fishes, a local provider of services to the homeless. The compelling nature of Brown's adventure raised questions that went well beyond how one man got put on a bus to a city where he'd never been.

He had no friends or family there. He had only a few days' worth of medication and a few bottles of Ensure. He had no plan for continuing medical treatment. It looked a lot like Las Vegas' Rawson-Neal Psychiatric Hospital was trying to get rid of him.

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The Bee's Phillip Reese sat down with the California Report and explained where things went from there.

"He did not know anyone here. He did not have any plan for medical care set up," Reese said.

Brown eventually found a new home in North Carolina with his daughter, but in the meantime the Nevada legislature became interested in the story.

"In those hearings, they mentioned that they had sent around 100 people to California, just in the last seven or eight months," Reese said. "And potentially many more to other states. So we had a feeling that this was not an isolated incident."

Then the Bee began reviewing five years' worth of Greyhound bus receipts that Nevada's mental health division had purchased. The reporters put together an interactive map showing where patients ended up.

(Visit the Sacramento Bee for the interactive version)

PatientBusingMap-SacBee — Via the Sacramento Bee. Source: Southern Nevada Adult Mental Health Services; data for-mid 2008 to early 2013; Analysis by Phillip Reese. Interactive by Nathaniel Levine.

Officials at the main hospital in question, Rawson-Neal Psychiatric Hospital, said a lot of people come to Nevada from somewhere else. They said the Brown case was an anomaly and that in all other cases there was a close family member or friend waiting at the destination to receive the patient who gets put on a bus.

To confirm that assertion, the Bee called at least 10 mental health agencies in counties all over California. Most were completely surprised at Nevada officials' assertions.

"San Francisco told us that they've had at least two patients in the last year alone come from this particular facility, Rawson-Neal, without a plan or family members," Reese said. "[They] just showed up, in the way that Mr. Brown did."

According to the Bee's review of bus records, 36 patients took buses to San Francisco. Without talking to those people, it's hard to know what happened once they got to the city. They might have sought help. They might not have. They might be in San Francisco now. They might be elsewhere.

Reese said he and his colleagues are trying to track down patients, as well as Rawson-Neal employees and former employees.

"We're hampered a bit, and rightfully so, by patient privacy laws," Reese said. "The Greyhound bus receipts had the names blacked out."

Nevada regulators told the Bee they reviewed protocols and instituted new rules that include requiring high-level approval of a Greyhound trip and a clear plan in place at the other end of the line for the patient. They also said they have taken disciplinary action related to Brown's case.

Cross-state busing of patients might not be considered a best practice in mental health care, but is it illegal? Reese said California's Justice Department isn't sure.

Los Angeles, though, has laws on the books explicitly prohibiting patient "dumping" of any kind, because it's something its own local hospitals did in the past. The San Francisco city attorney's office is checking local codes that might provide grounds for a civil action.

One-third of patients bused out of Nevada were shipped to California.

Reese points to "severe" budget cuts in Nevada. The bus trips began to spike in 2009, around the same time a recent round of budget cuts took place.

Plus, he said, "They never had an elaborate safety net for mentally ill patients to begin with."

UPDATE [4/26/13]

CARSON CITY, Nev. (AP) _ The federal agency that oversees Medicaid and Medicare compliance has put Nevada on notice of "serious deficiencies'' at a Las Vegas psychiatric hospital following reports of patients being improperly discharged.

An April 25 letter from the Centers for Medicare & Medicaid Services, first reported by The Sacramento Bee and obtain Friday by The Associated Press, gave Nevada 10 days to correct problems in its mental health discharge policies at Rawson-Neal Psychiatric Hospital or risk loss of federal funding.

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