SLO County facility staff allegedly falsified records in teen’s death

September 25, 2024

By KAREN VELIE

The mother of a 19-year-old woman who died at a San Luis Obispo County mental health facility, though no one noticed for eight to 10 hours, filed a wrongful death lawsuit in federal court on Monday seeking monetary damages and closure of the facility. The lawsuit names SLO County, Sierra Mental Wellness Group and eight of the group’s employees.

“She would still be alive if not admitted to the Crisis Stabilization Unit,” a unit employee told CalCoastNews. “It is so bad, the clients are in danger.”

Linda Cooper had her 19-year-old daughter Elina Branco of Paso Robles admitted to Twin Cities Community Hospital on the morning of May 15 because of a drug overdose, with plans to take the teen to a drug treatment program the next day. After assurances her daughter would be in good hands, Cooper agreed to have her daughter transferred to the SLO County Crisis Stabilization Unit for a one night stay.

Jason Hooson, who is part of the SLO Mental Health Evaluation Team, evaluated the teen’s risk of immediate self-harm in light of her current behavioral and substance use disorder. He approved the teen’s transfer to the Crisis Stabilization Unit.

“Client requires close monitoring, support and supervision to prevent recurrence of what likely would have been her death,” Hooson wrote. “Parent indicates that she believes client would use again if she were not directly transferred/admitted and fears client will overdose.”

Shortly after 5 p.m., Branco was transferred to the Crisis Stabilization Unit. Even though the policy is to take the patient’s personal items and clothing, Branco was placed in a bed with the clothes on her back. It is suspected she had narcotics on her person.

Staff at the unit documented Branco’s stay, noting on her chart that she went to bed at 9:35 p.m.

At 11:30 p.m. on May 15, and again at 1:30, 3:30 and 5:30 a.m. on May 16, the chart logs are identical: “Engaged in therapeutic rest without incident. Breathing is even and unlabored. Will continue to monitor for any changes.”

During shift change at 7:30 a.m., the log entry changes: “The client is lying in bed with eyes closed, breathing evenly and without labored breathing. Relevant information be passed on the day shift for continuity of care.”

However, it appears no one actually checked on Branco who the coroner calculated died between 10 p.m. and midnight on May 15.

By the time staff actually checked on Branco, between 8 a.m. and 8:30 a.m. on May 16, they realized she had died and was already in the process of “livor mortis,” according to the lawsuit.

Cooper called to talk to her daughter at 8:45 a.m. However, a unit staff member told Cooper her daughter was sleeping.

“Not only did defendants Janet Brown, Bethany Aurioles, Bonnie Sayers and Does one through three fail to monitor and check on patients for signs of medical distress, they lied about their welfare checks and falsified Branco’s medical record, a violation of a criminal California Penal Code 471.5,” according to the lawsuit. “Defendants’ failure was a serious dereliction of their duties and the one responsibility they had toward their client: to monitor for signs of distress.”

Shortly after the facility first opened in 2018, employees began complaining of mismanagement and failures to follow the law. For example, the unit is a 24-hour facility, and is only permitted to keep patients for up to 72 hours under limited circumstances, a requirement staff says is frequently ignored.

“Its all about keeping people in there, all about the numbers,” an employee said. “It is a mental health facility, though they allow people with serious physical health issues.”

Following the deaths of several mentally ill patients, including Andrew Holland, in 2018 the county opened the Crisis Stabilization Unit. The unit was supposed to “allow medical professionals to stabilize up to four community members at a time who are experiencing a serious mental health issue.”

SLO County outsources management of the unit to Sierra Mental Wellness Group, which has refused to discuss allegations of misconduct and the teen’s death. A handful of current and former employees of the unit spoke with CalCoastNews. They asked that their names not be listed in the article to protect their employment.

In Nov. 2023, an employee asked her supervisor why they were admitting people who did not qualify to stay at the unit because of a variety of reasons. A few days later, management removed policies and procedures from the policy and procedure binder.

Even so, an employee continued to randomly check to make sure the battery for the defibrillator was working as required by policy. Earlier this year, the employee discovered the battery was dead and informed a supervisor, who allegedly chastised the employee for checking the device.

A new battery was ordered though it was not taken out of the box.

Prior to the teen’s death, staff was required to do a check on patients every two hours through the unit’s video monitoring system, according to employees. Since the teen’s death, staff now does in-person checks every 15 minutes.

“Its all about keeping people in there, all about the numbers,” an employee said. “It is a mental health facility, though they allow people with serious physical health issues.”

Cooper’s attorney, Cameron Sehat with the Newport Beach-based Sehat Law Firm, is seeking general, compensatory and punitive damages. He is also asking the court for injunctive relief, such as closing the Crisis Stabilization Unit to ensure future client safety.

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