A few months ago, Lucille Edwards was working a day shift at John George Psychiatric Emergency Services when a man began to cry out. Edwards was making her nursing rounds in the central room, where she and a handful of other nurses tend to dozens of patients. Edwards and several other nurses then went over to the distressed man in hopes of calming him down. “He was distraught, very agitated,” said Edwards in a recent interview.

It didn’t take long for the nurses to understand what had happened. The man had been taking a nap in one of the large reclining chairs that are placed around the room, and when he awoke, he reached over, grabbed a juice cup that he had put on a table, and took a thirsty gulp. The man yelled and pointed to another patient who sat next him, accusing the other man of urinating in his cup while he was asleep. Edwards and other nurses did their best to prevent a fight, but other patients grew anxious by the man’s screams. Fortunately, they resolved the problem before anyone became violent.

For people unfamiliar with John George Psychiatric Emergency Services (PES) — Alameda County’s sole emergency mental health care facility, located in the hills above San Leandro — this incident might seem like an everyday hazard associated with treating mentally disturbed people, and perhaps resembles a tragicomic scene from One Flew Over the Cuckoo’s Nest. But according to Edwards and other nurses, the urine-drinking incident wasn’t caused by a “crazy” person who, for reasons unknown, peed in another person’s cup. In fact, nurses maintain the incident was due to severe overcrowding that has plagued John George for years.

According to nursing staffers, on that particular day, the central room at John George PES was full of patients. Every seat was taken, and more than a few patients were forced to sit on the floor or stand. When the central room, which is about 35-feet-by-45-feet in size, becomes crowded, patients become territorial: Those who have comfortable seats are reluctant to get up for any reason, because if they do, someone else will take their spot, and they will be forced to stand or sit on the cold floor. There are only a few other spaces in PES where patients are permitted to rest, and because patients must be accompanied at all times by multiple staff members, the routine is to keep almost everyone in the central room.

“The guy put his drink down and the other guy urinated in the cup probably because he was afraid to get up and go to the bathroom, because if he did, he would have lost his seat,” explained Edwards.

Nursing staffers say this incident was an example of the many kinds of conflicts that frequently erupt due to cramming so many mentally ill people into a small room with too few nurses to care for them. “There’s always a possibility of a riot if a fight breaks out because of the cramped, close quarters that people are in and the agitated states they are already experiencing,” said Stephanie Johnson, who is a John George nurse of thirteen years, has witnessed numerous brawls, and has been injured while trying to separate patients.

There are no beds at John George PES because it’s not considered an inpatient facility, and patients are only supposed to be kept for a maximum of 24 hours before they are discharged or transferred to a bed in the nearby inpatient unit of John George Psychiatric Hospital for more intensive care. As a result, many patients sleep sitting upright in chairs at night, while the rest crowd onto the floor, making it difficult to walk through the room.

People end up at John George PES for many reasons. Some arrive in ambulances, while others are escorted in police vehicles, and still others walk through the front door by themselves or are accompanied by concerned family and friends seeking help for their loved one. Many are committed involuntarily under the authority of California’s Welfare and Institutions Code 5150, which allows law enforcement officers and healthcare workers to hold a person against his or her will when they deem a person to be dangerous.

The purpose of John George PES is to stabilize people who are experiencing a mental health emergency, whether or not they have medical insurance. Many of the patients treated at the facility are chronically homeless or unemployed. Some suffer from alcohol and drug addiction, which compounds their psychological troubles. Some of them also have chronic physical ailments that make caring for them in their mental distress much more difficult. A big proportion of PES patients have fallen through the cracks of other institutions, or don’t have family members and friends who can help care for them. For those suffering from an acute psychological crisis, PES is the last thin mesh of the social safety net.

In recent months, nurses and other staffers at John George have increasingly been speaking out about the cramped conditions at the hospital, warning administrators and county health officials about troubling issues inside the facility that they say are undermining patient and worker safety and preventing patients from receiving adequate care. At public meetings of the Alameda Health System’s Board of Trustees, the governing body that oversees the John George Psychiatric Hospital, and before the Alameda County Board of Supervisors, which ultimately pays the hospital’s bills, nurses and other healthcare workers have noted that the number of patients admitted to the facility has nearly doubled in the past decade, while staffing levels have not kept pace, thereby increasing the number of injuries and violent incidents.

Staffers said during a series of recent interviews that it’s especially common for male patients to explode in anger at nurses and other patients when they feel that their personal space is being invaded, or when they’re asked to make room for people with disabilities or health problems who need to lay down.

“The stronger people sleep on the couch,” explained Johnson, referring to one of the few pieces of full-length furniture in the main room where a patient can comfortably recline. “We recently had a little lady with arthritis who needed to lay down, and we wanted to put her on one of the few couches that we have, and a man who was sleeping on the couch, when we asked him to please let the lady have it, he began yelling, ‘Hell no!’ and got very angry.” Johnson said they had to back off and find another spot for the woman for fear that the situation would escalate.

Nurses and other staff members say that while the problem of overcrowding is not new at John George, the situation is growing increasingly dangerous. And they blame hospital administrators not only for management decisions that they allege have made matters worse but also for creating a culture of fear in which speaking out could cost nurses their jobs.

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Ruby Sloan, a mental health specialist who has worked at John George Hospital since it opened in 1992, and who previously worked in the psychiatric ward at Highland Hospital, has seen lots of fights break out, but in recent years the problem has intensified, and the hospital administration has been unresponsive to pleas from nurses and other staffers, she said. “The PES has been overcrowded for more than ten years now,” said Sloan in an interview. “I’ve seen people bitten and stomped. I’ve had two concussions myself.”

In 2006, Sloan was working her shift at PES when a male patient became agitated and began lashing out at staffers. Sloan was standing nearby when the man threw a wild punch that landed square on the side of Sloan’s head, behind her ear, causing a concussion. Then in 2014, another male patient struck Sloan in almost the same spot with his fist, causing a second concussion. Both injuries forced Sloan to go on medical leave while she recovered. Sloan believes that her injuries, along with similar wounds sustained by her co-workers and other patients, could have been prevented if there were fewer patients crowded into PES and more nurses to look after them.

Overcrowding also results in critical gaps in patient care, said several other PES staff members whom the Express has agreed not to identify because they fear retaliation by hospital management. According to several accounts, last year nurses had difficulty providing care to a patient experiencing a life-threatening medical emergency inside PES. “We had to try to help this person right there on the spot,” said a PES staff member. “This was a lady who was in serious trouble, but because it was so overcrowded, and because some of the patients don’t know any better, we had people interrupting us the whole time, coming up behind us, asking for snacks, for cookies, or if they could go to the bathroom.”

In multiple emails and phone messages, I repeatedly asked the Alameda Health System’s communications director Jerri Randrup and agency spokesperson Jennifer Schutz about recent events in PES, but neither responded to my questions. Instead they emailed me the same undated, unresponsive one-page statement three times.

Edwards, Johnson, and Sloan all said that frequent overcrowding inside John George PES also means that many patients have to eat their meals — which are served in Styrofoam trays with plastic utensils — while sitting on the tile floor, and that at night, some of the patients are expected to sleep on the hard floor with only a pad and a blanket to insulate them. According to the Alameda County Mental Health Board, a public committee that advises the county board of supervisors on mental health services, there are frequently upwards of twenty patients sleeping on the floor at night in PES because the facility is overcrowded.

“There’s nothing therapeutic about this,” said Johnson. “We’re going backward.”

“The floor is cold, and there’s no good ventilation in the PES,” added Edwards. The room is normally pungent with the smell of soiled clothing. Because the toilets are locked, and a nurse must accompany a patient when they need to use the toilet, patients frequently urinate on themselves. “A lot of people end up leaving the hospital more traumatized than when they came in,” said Edwards.

On November 24, 2015, Edwards, Johnson, Sloan, and about forty other nurses and staffers went to the meeting of the Alameda Health System Board of Trustees, which oversees the John George Psychiatric Hospital, and implored the board to find a solution to the overcrowding. The public appearance of so many hospital staff at a board of trustees meeting — effectively going over the heads of their own hospital’s administrators — was unprecedented.

“Overall morale at John George is at an all-time low,” said BJ Wilson, a nurse who has worked for many years at John George’s PES, during the public comment period. Wilson added that in the months leading up to the trustees’ meeting, PES had exceeded its capacity on multiple days, and that if the conditions are allowed to continue, violence will ensue and the quality of patient care will further decline. “Sooner or later,” Wilson warned the trustees, “something bad is going to happen.”

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John George PES has a long history of bad things happening. In 1998, state regulators investigated the facility and found that the hospital’s administration had set up substandard injury-prevention programs, and that assaults committed by patients against other patients and against staff were common. The state issued citations, but not much changed. Again in 2003, state regulators made the same findings. Dean Fryer, a spokesperson for the California Occupational Health and Safety Administration (OSHA), told news reporters at the time that John George’s administrators had made a “dismal showing,” and that, in fact, the hospital’s leaders had behaved in a “defiant” manner during the summer of 2003 by not increasing security and staffing as OSHA had advised.

Then in November 2003, tragedy struck. Rene Pavon, a 48-year-old patient who was being examined by veteran physician Erlinda Ursua, picked up a heavy blunt object and knocked the doctor over the head. Pavon then strangled Ursua to death using the doctor’s scarf. The attack was not discovered for at least thirty minutes because Ursua had been examining Pavon alone, in an isolated examination room, a practice that OSHA and others had previously advised the hospital’s administrators to end. Then in December 2003, Mark Oyarzo, a 38-year-old patient, hanged himself with a shoelace. Further investigation concluded that both of these deaths were preventable and partly due to under-staffing and poor safety practices.

Then in 2005, another patient committed suicide by hanging herself from a bathroom door hinge with a piece of clothing. This spate of tragedies — Ursua’s death, multiple suicides, and even more numerous assaults, some of which the hospital’s administrators did not immediately report to state health officials — caused the Alameda County Civil Grand Jury to investigate John George PES. The grand jury wrote in its final report, published in 2006, that the hospital appeared to be undertaking reforms suggested by state regulators but that “questions still remain regarding how well the training program is implemented and how policies and procedures are enforced” and that “safety concerns will remain until the facility’s staffing needs are met.”

The grand jury singled out the hospital’s tendency to have too few nurses on shift and too many patients crowded into PES, calling it an “ongoing challenge.” The number of patients often swelled to levels far exceeding the state mandated nurse-to-patient ratio, which, according to the grand jury report, should have been one-to-five.

Then, starting in 2007, the county’s mental health care budget began taking hits — damaging cutbacks that undermined any progress that had been made. At an Alameda County Board of Supervisors meeting on January 11 of this year, Manuel Jimenez, director of the county’s Behavioral Health Care Services, which helps pay for mental health care at John George Hospital, said that more than $70 million had been cut from the county’s mental health care budget since 2007.

“I know there are problems at John George,” said Jimenez during the meeting. When asked by county Supervisor Keith Carson to explain the problem of overcrowding, Jimenez listed factors mostly beyond the hospital’s control. According to Jimenez, budget cuts have reduced the capacity of John George Hospital’s inpatient facilities, which has forced the hospital to hold more patients in PES, rather than transferring some of them to the inpatient beds. Jimenez added that budget cuts have been compounded by the fact that John George PES is the sole psychiatric emergency services facility for the entire county, and Alameda County has a large and growing population of poor people living in “concentrated poverty” and other conditions of stress and trauma that produce an abnormally high incidence of mental health crises. Jimenez told the board of supervisors that social and economic conditions in Alameda County have caused it to have “one of the highest 5150 rates in the state.” In fact, according to California’s Office of Statewide Health Planning and Development, Alameda County has the highest per capita incidence in the state of involuntary holds placed on individuals experiencing a mental health emergency — 11 per every 100,000 people — with the next highest county only having placed 6.4 involuntary holds per 100,000.

Another factor causing overcrowding in PES is the hospital’s high readmission rate. According to the county’s Mental Health Board, too many patients make repeated visits, because there are too few mental health services available to them. For many mentally ill people, especially those who are homeless or very low-income and lack medical insurance, it’s difficult to obtain treatment for substance abuse, to get into transitional housing, and to access medication, counseling, and other resources and therapies that would keep them from spiraling into another crisis. According to a recent Mental Health Board report, the high readmission rate at John George PES had the potential to feed a “vicious cycle of overcrowding,” resulting in “patients being discharged and being readmitted when they fail to function outside the hospital setting.”

Nurses at PES are already familiar with this cycle. Sloan said in an interview that lots of patients return to PES week after week, often as walk-ins, but others arrive repeatedly in ambulances after having fallen into a manic or severely depressed psychosis.

“There is nowhere else for many of these people to go to,” said Sloan. She said many of the mentally ill who are homeless sleep in the bushes around the John George Hospital campus, spending the night out in the elements, or wandering the streets of San Leandro and East Oakland before making their way back to PES.

I recently walked around the hospital grounds and noticed pillows, blankets, sheets of cardboard, and possessions stashed in crawl spaces dug out beneath palm trees and shrubs. There were impressions of curled human bodies in the compacted dirt where people had recently slept.

“There is not enough in the way of services to help this population deal with their lives and stay out of the hospital,” said Sloan.

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According to Sloan and other caregivers who work at John George, some of the causes of overcrowding in PES are also due to ill-advised decisions made by hospital administrators. In fact, staffers say PES became dangerously overcrowded because of a solution devised by administrators for another problem.

In the past, people experiencing a mental health crisis could take themselves, or be taken by police or paramedics, to any emergency room at any hospital in the county. Under this old system, psychiatric patients were diagnosed and sometimes treated at public and private hospitals in Berkeley, Oakland, San Leandro, Fremont, Livermore, and elsewhere. But this all changed with the introduction of the “Alameda Model.”

The Alameda Model was developed by Scott Zeller, an award-winning physician who until last year was the chief of psychiatric emergency services at John George Hospital. The problem that Zeller was trying to solve was the unreasonable and inefficient wait times that patients in Alameda County faced when they arrived at a standard hospital emergency room in the midst of a mental health crisis. According to a paper published by Zeller in the Western Journal of Emergency Medicine in 2013, a survey of emergency department directors in California found that “the average wait time for adult patients with a primary psychiatric diagnosis in the [emergency department], from the decision to admit until placement into an impatient psychiatric bed or transfer to an appropriate level of care, was 10.05 hours.” Zeller concluded that this time-consuming method — called “boarding” — amounted to a “costly practice, both financially and medically,” and that “the psychiatric symptoms of these patients often escalate while they are boarded in the [emergency department].”

Zeller sought a way to reduce these wait times and more quickly provide care for psychiatric emergency patients. His solution was to assign one hospital as the primary point of intake for mental health patients in need of emergency care and to guarantee that other hospital emergency departments could immediately transfer psychiatric patients to John George’s PES. The result is that other hospitals now send psychiatric patients to John George, rather than boarding them and treating them. And the police and EMTs also bring psychiatric patients directly to the John George PES.

Troy Nixon, who works as a nurse in the emergency intake area of John George PES, where patients arrive in ambulances, assesses patients to determine whether they should be admitted to PES or referred to a counselor or a substance abuse center. “I want them to have full awareness of what’s going to happen and what to expect if we admit them,” Nixon said in an interview. “But if a person says, ‘I want to kill myself,’ then it’s automatic. They have to come in, even if they don’t want to.”

According to Nixon, the Alameda Model has drastically increased the number of patients being admitted to PES, and while this might be good for emergency departments at other hospitals, which have fewer resources to care for those experiencing a mental health crisis, it has also put a crushing burden on PES staff and undermined patient safety and care.

Nixon and other nurses believe that the John George PES needs to cap the number of patients it can hold at any given time. According to Nixon and his fellow nurses, the hospital’s administration has purposefully designated PES as a special facility that not only has no cap, but also does not have to abide by any nurse-to-patient ratio or a capacity limit set by the county fire marshal.

“Because we are encouraging patients to be sent here, or to just come in on their own, we end up having to deal with the huge number of people who may not really need to be in our care, and it takes our attention away from the people who seriously need our help,” Nixon said. “It’s almost like an assembly line, this higher volume of people. It’s like we’re a McDonald’s and we got 1,000 customers, and we are having to take short cuts to serve people, to get them in and out the door.”

PES staffers have petitioned Alameda Health System (AHS) managers to assign a cap of fifty patients and to ask other hospitals delay transferring psychiatric patients and treat them in their own facilities, and for police and paramedics to transport patients to other emergency departments whenever PES reaches its cap. PES staffers also have requested that AHS hire more mental health crisis workers to be assigned to emergency rooms in Alameda, San Leandro, and Highland hospitals so that these locations can provide care for patients who can’t be transferred to the PES when its cap is reached.

When I asked AHS representatives why John George PES has no cap or a capacity limit set by the fire marshal, I received only a single-page statement thanking me for my interest. “JGPH is the only provider available within Alameda County to care for patients experiencing a psychiatric emergency,” the statement read. “Similar to medical emergency departments, there are times when the need exceeds a manageable volume.”

The statement did not explain why the hospital’s PES has no patient cap or building capacity limit, nor why the hospital shifted to the so-called Alameda Model. In fact, AHS spokeswoman Jennifer Schutz would not even respond to my question as to what year the Alameda Model was first implemented.

Zeller, who now works for a private Houston, Texas-based healthcare company called JSA Health Telepsychiatry, wrote in an email to me that the Alameda Model has been in effect since 2005. Zeller contended, however, that it can’t be blamed for overcrowding at John George PES. He also said PES can’t cap the number of patients it admits. “Federal law recognizes psychiatric emergencies as emergency medical conditions, technically equivalent to medical emergencies like heart attacks or car accidents. So it is impossible for the John George Psych ER to ever say, ‘We are full, no patients can come here,'” wrote Zeller. “Some concerned staff may have told you that they believe John George should be able to have a ‘cap’ at a certain number of patients. But no ER in Alameda County is permitted to do this. And only John George has psychiatric professionals on duty 24/7. Where would the patients having psychiatric emergencies then go if the Psych ER said they were ‘full’?”

But PES staffers said they are not advocating for turning anyone away who shows up at the facility. Rather, they want John George PES to inform first responders and other emergency hospital rooms when PES becomes overcrowded, and to prevent transfers of patients to PES from other emergency rooms until conditions improve.

Zeller argued that this would be “not fair” to non-psychiatric patients with medical emergencies in other emergency rooms that are overcrowded, as well. In his 2013 research article about the benefits of the Alameda Model, Zeller also noted that emergency rooms can save $2,264 for each psychiatric patient they do not have to board. But PES staffers maintain that Zeller’s commitment to have PES absorb all psychiatric patients, without limits, is doing more harm than good for patients and workers.

In public meetings and in letters to the AHS board and Alameda County supervisors, PES staffers have asked to end the Alameda Model in order to reduce overcrowding. “In a space that is full at 50 [patients], PES regularly reaches a census of 80 [patients] on weekends and 70 is seen with increasing frequency on weekdays,” wrote PES staff members in an open letter that they distributed at the AHS trustees meeting in November 2015.

They wrote that the overcrowding is caused by the absence of any policy to divert patients away from PES when it’s already filled. “For patients in need of acute stabilization, they arrive in PES finding resources stretched thin. They often find that there are no benches where they can sit or rest, which leads to assaults and agitation. They find that psychiatrists are grappling with bloated caseloads and demanding deadlines, leading to rushed interactions. They find that nurses are often assigned to 8 or 9 patients, in violation of state law and safe practice standards, and have little time for therapeutic intervention aside from preventing violence, crowd control and administering medications to those most in need.”

In public meetings and official reports, AHS administrators have acknowledged the overcrowding problem at John George PES but have refused to speak about it with the news media. I requested an interview with Guy Qvistgaard, chief administrative officer of John George Hospital, and Judy Linn, director of nursing, but AHS communications director Jeri Randrup and spokeswoman Schutz did not acknowledge my request.

However, an internal report conducted last December by Rick Kibler, vice president of compliance and internal audit for AHS, found that the nurse-to-patient ratio of one nurse per every six patients, which is the standard for the entire John George Psychiatric Hospital under its state license, is “not consistently met” in the PES. The same report noted, however, that there is no legal classification for the John George PES facility, and therefore under state law, there is no specific nurse-to-patient ratio that the PES is mandated to follow. However, because the PES fits the state and federal criteria for being both an emergency department and a psychiatric unit, the facility must adhere to either a one-to-four or a one-to-six nurse-to-patient ratio. According to Kibler’s report, “the California Department of Public Health is investigating the matter of licensed nurse-to-patient ratio for PES, and will provide a recommendation at a later date.”

PES staffers believe that AHS administrators have exploited this lack of clarity in order to accept more patients, while keeping staffing numbers down, in order to maximize the hospital’s billing revenue.

According to Nixon and other nurses, AHS management has tried to keep the problem of overcrowding and staffing shortages at John George from becoming public, and has been unresponsive when staffers have raised the issue of overcrowding in internal meetings. In fact, the internal AHS audit conducted by Kibler was only conducted because forty PES nurses and other staffers approached the AHS board of trustees at its November 24 public meeting last year and spoke at length about the problems at John George.

And PES staffers are continuing to raise the issue publicly. At the January 11 meeting of the Alameda County Board of Supervisors health committee, Nixon presented a graph showing that total annual visits by patients to John George PES jumped from 9,645 in 2007 to 16,116 last year, while staffing hasn’t increased sufficiently to meet this explosion in admissions. “It’s great that we are finally acknowledging these problems exist,” Nixon told the supervisors and county health officials during a public comment period. “We need to set a maximum capacity at which we can safely, therapeutically manage things. Right now, there’s simply no floor space, and we’re being forced to free up space, and figure out who we can discharge faster. It’s a tragedy.” Nixon ended his comments by noting that John George PES is possibly the only hospital in the state without a cap on the number of patients who can be in the building.

I contacted the Alameda County Fire Department’s fire marshal about Nixon’s claim. According to spokesperson Aisha Knowles, John George Hospital’s original building and permitting plans dating back to 1989 do not indicate an occupant load for the building housing the PES. State health and fire officials told the county fire marshal that a waiver was granted in 2004 to convert a building on the John George campus into the PES facility. The county fire marshal has requested records from the state related to this waiver, which should indicate if an occupant load was ever assigned to the PES by state fire and health officials. The county fire marshal, however, has yet to receive these records.

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Nurses and other staffers say that last year, after they began demanding action on the issue of overcrowding, John George Hospital administrators became increasingly hostile, and that some staffers have been punished for speaking with state regulators and county officials.

“I have seen a lot of different administrations over my career,” said BJ Wilson about the executives who run John George Hospital and other AHS mental health facilities. “The current group, which has been here for the last eight years or so, they have not been receptive to the staff’s concerns. Some things, they do appear to be punitive, and when people have to work in a situation where they feel like their livelihood is jeopardized, it’s working in fear.” Wilson said fear has kept many AHS mental health workers from raising the issue of overcrowding with administrators. (In fact, all of the nursing staffers interviewed for this story declined to be photographed because of fear of retribution.)

Another nurse, speaking on the condition of anonymity, said many of the current AHS executives came to the system from private sector hospitals where nurses and other employees have fewer protections and work for less pay, and where the goal of increasing hospital profits often takes precedence over issues such as staffing and patient care. “In the private sector, if you piss off the boss, they get rid of you,” said the nurse, who believes that many current AHS executives are bringing this mentality into the county’s public health system.

Lucille Edwards was one of the speakers who addressed the AHS trustees at their board meeting last November about problems at John George PES. According to Edwards, after that meeting, her immediate supervisor called her into the office at least five times and reprimanded her for things like using an “irritated voice” in the workplace.

“We all know this stems from my going to the board of trustees with the other nurses and speaking about the problem. I was one of the main speakers,” Edwards told me. “I had no problems from 2011, when I started working here, up until the trustees meeting. So the record speaks for itself.”

Wilson told AHS trustees at their November board meeting that nurses used to only “fear being assaulted by patients, but now the fear is staff is being assaulted by the administration. … If you talk, speak out, you’re going to be reprimanded, hauled in, questioned, and your credibility is going to be on the line.”

AHS spokesperson Schutz did not acknowledge my request to interview Judy Linn, director of nursing at John George, so I was unable to ask hospital executives about any recent disciplinary actions at the facility. Schutz also did not return my phone calls seeking comment about discipline issues.

Another nurse who spoke to me on the condition of anonymity said that PES workers who are injured on the job are sometimes treated as though their injuries are their own fault. “When you get assaulted by one of the patients, it’s almost like you get another punishment afterward from the management,” the nurse said. “They try to reassign you or keep you from being able to work again. They don’t say it to you, but they do things to make it clear.”

According to AHS records and other sources, John George administrators attempted last year to remove a PES manager who sided with nurses over the issues of overcrowding and the demand to establish a nurse-to-patient ratio. According to an open letter distributed publicly by PES nurses, Frederick Tatum, the nurse manager in PES, was placed on administrative leave after he communicated with state regulators about possible fire code violations and requested clarification regarding nurse-to-patient ratios from hospital executives and state regulators. According to the open letter, the hospital administration placed Tatum on administrative leave and investigated him for reasons that were not disclosed, but the administration found no evidence of misconduct, so AHS executives then offered Tatum a “hefty severance package” if he would agree to voluntarily resign.

Tatum declined to be interviewed for this story. But another nurse, again speaking on condition of anonymity, said that Tatum’s administrative leave was viewed by PES staffers as a signal from administrators that any communication with regulators, AHS trustees, county officials, and the public, would be punished. The nurse called the situation “administrative bullying.”

Many PES staffers view the current situation as a crisis. Late last year, 150 John George PES staff members signed a petition calling for a cap on the number of patients who can be admitted the facility. They also called for Tatum’s reinstatement. And the PES workers called for the removal of Linn, the John George Hospital’s director of nursing, “for her responsibility in targeting whistleblowers [and] creating a hostile work environment.”

According to a letter sent on December 8, 2015 by Derrick Boutte, an AHS employee and the AHS chapter president of the union SEIU 1021, to Delvecchio Finley, the CEO of AHS, a majority of John George workers represented by SEIU 1021 voted that they have no confidence in Linn’s ability to function as the facility’s director of nursing. Tatum’s administrative leave was recently rescinded, but Linn remains the director of nursing. And John George PES still has no patient cap or a clear nurse-to-patient ratio.

When and how these larger issues will be resolved is unclear. In the meantime, the underlying social and economic problems that many believe are the cause of mental health emergencies are only getting worse. “The housing crisis and the rapid gentrification of previously low-income neighborhoods has impacted the population of homeless and hungry in Alameda County,” wrote PES staffers in their open letter. “Even when not in a mental health crisis, John George is a refuge for the needy, indigent, and historically under-served in our community.”