A terribly injured 33-year-old homeless male schizophrenic recently was found lying hidden in a church in Chesterfield County.

He was discovered with multiple displaced fractures in the lower pubic bone, a break on the left side of the sacrum (base of the spine), a large amount of blood in his pelvis, a nondisplaced fracture in the back part of the T5-T6 vertebrae and many other serious injuries. He was wearing both a catheter and a colostomy bag.

He had previously been admitted to and discharged from Virginia Commonwealth University Medical Center (VCU) with those injuries. It is at least unusual, and in most cases prohibited, for nursing homes to accept patients with schizophrenia. Yet upon discharge from VCU, the man had been admitted to and discharged from two skilled nursing facilities, Hanover Health and Rehabilitation Center (Hanover) and Colonial Heights Rehabilitation and Nursing Center (Colonial Heights).

Each is run by New Jersey-based Medical Facilities of Virginia (MFA). Each, thus unsurprisingly, is rated one star of five by Medicare for staffing. Neither has recently reported having mental health support capabilities.

The medical journey of that unfortunate patient would be literally unbelievable had it not occurred.

• He was transferred from VCU to a skilled nursing facility without a history of providing mental health services, from there to another skilled nursing facility with a similar history, and finally discharged from that one onto the street with his horrific and life-threatening injuries;
• He was not transferred from VCU to Hiram W. Davis Medical Center (Davis) in Petersburg. That state hospital had the distinct advantage of actually being able care for him.

So many questions.

The two actual transfers. While at VCU, the man was diagnosed with schizophrenia.

Under federal regulation, skilled nursing facilities are prohibited from accepting patients with schizophrenia, a mental disorder, unless Virginia Department of Behavioral Health and Developmental Services  (DBHDS) conducts an independent evaluation or one of the exceptions listed in the regulation is granted. The public does if any of that happened.

Nonetheless, VCU transferred him to Hanover, ten miles northwest of the hospital. The patient subsequently was transferred from Hanover to Colonial Heights, 35 miles south.

The public deserves to know, among other questions, why a schizophrenic as severely injured and vulnerable as this man was discharged:

• from a critical care hospital at a state university to a skilled nursing facility with a record of understaffing;
• from one MFA SNF to another with a worse staffing record; and
• from Colonial Heights to the street.

The poor man must really have wanted out of Colonial Heights. In that at least he was rational.

The MFA nursing facilities. Nursing facilities report their daily nurse and non-nurse staffing quarterly to the Centers for Medicare and Medicaid Services (CMS).

• Hanover reported no mental health services hours in the latest available quarter (Q2 2024); and
• Colonial Heights in that same quarter reported neither physician nor mental health services hours on their payroll.

I have edited for length and combined the two reports here. Please note that they combined for zero hours in other critical jobs like dietician and pharmacist.

It is reasonable, or should be, for a patient and his caregivers to expect that a hospital as part of the discharge process evaluates where to send each patient. Federal law requires them to do so.

But moving on to current criminal charges, a physician somehow connected to Colonial Heights is accused of neglect and abuse of that man.

Two key points about that Colonial Heights discharge:

• The government alleges that that physician never actually saw the patient but declared that schizophrenic man mentally fit for discharge.
• A Colonial Heights nurse checked out a homeless man while he was wearing a catheter and a colostomy bag. Foley catheters need to be cleaned every day and the drainage bag changed two times a day. Colostomy bags should be emptied when 1/3 to ½ full and the system changed every 3-5 days. Sepsis follows if that schedule is not kept. It was not. And there was no reason for Colonial Heights to expect it to be.

The transfer that did not happen.

It is reasonable and necessary to ask why VCU did not transfer the patient in question to state hospital Hiram W. Davis Medical Center (Davis) in Petersburg. Davis is a well regarded and well staffed skilled nursing facility operated by DBHDS specifically for patients with schizophrenia and other mental disorders.

A Public Health Crisis. The two parallel and ongoing criminal cases involving Colonial Heights throw light on a complete breakdown of the state medical system in central Virginia.

The patient about whom this specific story has been told could and, had he been older when injured or had he remained unfound for another day, he probably would have died. In the other pending case of alleged abuse and neglect of a Colonial Heights patient, the woman did die. The two criminal cases will take their course.

But these series of events describe a public health crisis involving a much broader range of participants than just those charged with crimes at Colonial Heights. The Secretary of Health and Human Resources, the Board of Health, the Board of Medicine, the Virginia Board for People with Disabilities, the Health Commissioner and the head of DBHDS owe us answers.

We look forward to what we expect will be an imminent announcement that they will investigate and report to the citizenry in plain language both what happened and what will be done about it.