Several Iowa hospitals, including one at the center of a controversy involving the shooting death of a Parkersburg coach, have been accused in recent years of discharging psychiatric patients before they were stabilized.

The problems in Iowa are not unique. Nationally, patient access to hospital psychiatric services has long been an issue. Hospitals have been fined for discharging psychiatric patients prematurely and have faced lawsuits for boarding mental health patients in emergency rooms for days on end.

In the Parkersburg case, Mark Becker was discharged last Tuesday from the mental health unit at Waterloo's Covenant Medical Center, a day before he allegedly shot and killed Ed Thomas.

It's not known what treatment Becker received at Covenant, and it's not clear whether the hospital did anything wrong in its handling of the case. Law enforcement officials have said the hospital failed to notify them when it discharged Becker, but hospital officials have denied any wrongdoing.

A Des Moines Register review of hospital accreditation and inspection reports shows that over the past four years Covenant has been cited for a variety of problems related to psychiatric care.

Earlier this year, state inspectors found that the director of Covenant's psychiatric unit for the past decade had only a degree in physical education with endorsements in teaching and coaching.

Late last year, the hospital was written up for dozens of violations related to mental health patients and the hospital's improper use of restraints.

And in 2005, there were two incidents that involved the hospital denying treatment to psychiatric patients and discharging them before they were stabilized.

Covenant officials did not comment on those findings when asked about them last week.

Other hospitals in Iowa found lacking, too

But it is not the only hospital to face such allegations. State records illustrate the range of problems in Iowa:

- In August 2005, Allen Memorial Hospital in Waterloo was cited for failing to protect the safety of a 15-year-old girl in the hospital's mental health unit. The girl had attempted suicide and was diagnosed with depression. Her health assessment noted that she was attracted to older men, but her treatment plan and room assignment did not take that into account. A week after admission, the girl was involved in an "incident of a sexual nature involving an adult male patient in the mental health unit," inspectors reported. The girl was transferred to another hospital.

- Three months ago, Allen Memorial Hospital was cited for employing off-duty police officers - each armed with a loaded gun, a knife, a Taser, pepper spray and a nightstick - as security guards in the mental health unit. The officers weren't trained in hospital restraint procedures. On March 3, a patient who had the mental capacity of a 10-year-old child became combative and the officer used his Taser to subdue the patient. The hospital was later cited for failing to report patient abuse and for allowing the police officers to "threaten and intimidate" patients. The hospital recently hired trained, unarmed security guards to work in the mental health unit.

- In 2005, an Iowa sheriff transported a man to Covenant Medical Center for a psychiatric evaluation. According to inspectors, the hospital discharged the man before he could be seen by a doctor or given the required medical screening to determine whether he was stable.

- In 2007, police took a suicidal woman to Davis County Hospital in Bloomfield and told a physician, Dr. Dorothy Cline-Campbell, that the woman had taken "a bunch of pills." Cline-Campbell allegedly "blew up" at the officers and said, "What am I supposed to do with her? We don't do that here," and told the officers to take the woman to a different hospital. When interviewed by state inspectors, Cline-Campbell allegedly admitted that she had told the police "the easiest thing to do" was for them to go elsewhere because "Davis County Hospital doesn't provide psychiatric services."

- In 2005, an 11-year-old child was taken to the Orange City Health System emergency room by ambulance after being found at home, unresponsive and blue in the face, with a plastic bag over her head. The patient was sent to another hospital more than an hour away. A quality-of-care review by an outside agency faulted the Orange City hospital for the unsupervised transfer of a suicidal patient. The reviewer noted that the transfer took place immediately after an interrupted suicide attempt and that the child was still at risk for developing swelling of the brain.

Sylvia Piper of Iowa Protection and Advocacy says the state needs to develop an acute-crisis care system to respond to people with urgent psychiatric issues. That would provide relief for police and emergency room nurses who aren't always equipped to handle such matters, she said.

Margaret Stout of the Iowa chapter of the National Alliance for the Mentally Ill agrees.

"Iowa needs to see if we can't come up with a better way to handle people in crisis, particularly in our rural areas," she said.

In Iowa, there are 644 hospital beds available for psychiatric patients. The number would be 733 if it weren't for a shortage of psychiatrists that has kept 89 beds empty and inaccessible to patients.

"There is a critical shortage of psychiatrists in the state," said Roger Tracy, assistant dean at the University of Iowa's College of Medicine. Three years ago, he studied the issue and found that Iowa needed to expand its roster of full-time psychiatrists by 63 practitioners, or 29 percent.

Of the 50 states, Iowa ranks 47th in the number of psychiatrists per capita. The shortage can lead to problems when police bring people to emergency rooms on nights or weekends hoping for psychiatric evaluation.

Lengthy waiting time leads patients to walk out

Nationally, about 6 percent of all emergency room visits are related to mental health problems, but a psychiatric patient's waiting time for actual treatment - as opposed to mere admission - often ranges from eight to 24 hours. Some patients give up and voluntarily leave the hospital without being treated.

A 2008 study of almost 300,000 emergency room visits showed that nationally, patients with psychiatric complaints are twice as likely as other patients to walk out of the hospital before being treated.

A separate study by the American College of Emergency Physicians found that a shortage of psychiatric beds has forced hundreds of hospitals to board mental health patients - including children - in their emergency rooms until a bed opens up.

Hospitals in Massachusetts and Rhode Island have reported boarding psychiatric patients for up to a week in their emergency rooms.

All U.S. hospitals that accept Medicare funding are required to comply with the Emergency Medical Treatment and Labor Act, a 23-year-old federal law that prohibits hospitals from discharging patients or withholding treatment while the patients are in an unstable condition.

The intent is to prevent "patient dumping" - the practice of discharging patients either to avoid providing treatment or to screen out people who can't pay for their care.

Over the past five years, the annual number of investigations related to alleged Treatment Act violations in Iowa has grown from five to 19, according to state and federal records.

Mental health advocates say psychiatric patients are particularly vulnerable to patient dumping because they're often uninsured.

"As for patient dumping, there isn't any plausible reason to think things have been getting better," said Dr. Sidney Wolfe of the consumer advocacy group Public Citizen. "It's cheaper for a hospital to dump a patient and save $10,000 or $20,000 than it is to pay no fine or, perhaps, a small fine."

Last year, Esmin Green, a 49-year-old mother of six who suffered from depression, died in a waiting room at Kings County Hospital Center in New York. She had waited 24 hours to be seen by doctor before she fell from a chair onto the floor. Security cameras showed that another hour passed before any workers rendered assistance.

Earlier this year, two southern California hospitals were accused of improperly dumping psychiatric patients on downtown Los Angeles' east side where thousands of homeless people live. The hospitals settled the case for $1.6 million. City officials alleged that over two years, as many as 150 patients were dumped on Skid Row.

Covenant faces citations on psychiatric services

State inspectors and hospital accreditors have repeatedly cited Covenant Medical Center for problems related to its psychiatric services, most recently in February.

In 2004, the Joint Commission on Accreditation of Healthcare Organizations, now known simply as the Joint Commission, inspected the hospital and found problems with the psychiatric services and "several issues of safety" in the mental health unit.

The commission found that an emergency room patient had been placed in physical restraints without the required physician's order. Another patient was given an anti-psychotic medication with no record of a physician's order, and inspectors found pre-printed medication orders for painkillers in the psychiatric unit.

In 2005, a 29-year-old woman had gone to Covenant's emergency room on a Thursday afternoon complaining of post-partum depression and asking for an immediate psychiatric evaluation. She had been seen earlier in the day by a doctor at the nursing home where she worked and was advised to leave the facility for her own safety.

At the hospital, a nurse told the woman to call the Covenant Clinic psychiatric office the following Monday to schedule an appointment. The woman was told she was being discharged and being given a drug to help her sleep.

The woman objected, saying she couldn't wait four days to see a psychiatrist. The Covenant nurse explained that the clinic office was closed for several days and Monday would be the soonest the woman could get help.

The woman, who was familiar with the legal requirements for emergency psychiatric services, said, "Then call (the hospitals in) Mason City or Waverly. I am a nurse and I know you have to do that."

According to hospital records, the woman insisted on speaking to a psychiatric nurse, but later agreed to call the clinic the following Monday.

Federal agency asks for state inspections

The Iowa Foundation for Medical Care, which monitors the quality of care in Iowa hospitals, reviewed the case and in a written report alleged that the woman was not adequately evaluated by Covenant Medical Center's staff.

The foundation's report on the matter stated, "Just because the patient declined to be admitted does not relieve the hospital from psychiatric evaluation in the emergency room. ... The patient was not evaluated adequately to determine if she was stable. A clue was that she was advised to leave her employment at the nursing home 'for her own safety.' "

Six months ago, the federal Centers for Medicare and Medicaid Services determined that Covenant's private accreditation could no longer serve as an indication of compliance with government health and safety standards.

The federal agency authorized the state to inspect the hospital, which resulted in citations for dozens of violations related to the inappropriate use of restraints on psychiatric patients.

Covenant was cited for failing to inform the state that a patient died after being in restraints for about 44 hours. The patient died 13 hours after the restraints were removed, although the cause of death is not detailed in the inspectors' public report.

State inspectors have found other serious problems at Covenant unrelated to psychiatric services.

In February, they reviewed 20 instances of medication errors and found that in 12 cases there was no indication of the patients’ physicians being notified of the mistakes. The hospital also was cited for inadequate infection control and failure to maintain the building and equipment.

Some of the electrical examination tables were last inspected in 1999, and some beds with electrical power were last inspected in 1983. Emergency equipment, such as cardiac monitors and defibrillators, were 18 months or more past their inspection date, and supplies in one of the “crash carts” had expired months earlier.

Inspectors also alleged inadequate maintenance and monitoring of the dialysis machines, declaring an immediate and severe threat to the health and safety of patients. The hospital was required to take immediate corrective action before inspectors completed their work and left the building.