What makes Sammy run?

Huge and helpless, schizophrenic and hypertensive, Sammy Allen has fallen between the administrative cracks of a local mental health system that can't seem to get its ACT together

Sammy is assigned to an eight-bed room approximately 30 feet long by 10 feet wide, with each of the beds spaced a few feet apart. The mattresses and sheets are stained. A ceiling panel over the room's two fluorescent lights is missing. Two of the three ceiling fans don't work. The doorknob is falling off. A few broken-down bureaus are scattered around the room. The bathroom consists of a shower the size of a large telephone booth and two toilets, both missing their stall doors. For this Allen pays $340 a month. (DeFreece acknowledges that boarding homes can be unappealing places to live, but he points out that no one else will take the population with whom ACT works.)

Jefferson House has 11 rooms and 58 beds. Its population fluctuates, but recently 54 men and women lived there, 28 of whom were DMHMR clients. It provides three meals daily, plus it posts someone--usually an ex-DMHMR consumer--at the front desk. Curfew is at 10 p.m., and no one is allowed out of his room after 11 p.m.

Sammy spends much of his time watching television, either sitting in the day room or in his room, surrounded by his garbage bags filled with soiled and foul-smelling clothes, some of which are starting to mildew. He urinates in his bed, and the sheets are not changed. He is constantly harassed by residents and the desk clerks to wash, to lower his voice, and to stop his ranting.

At different times a resident tries to sell Sammy cufflinks, a belt with "Ellis Unit Death Row" stamped on its buckle, a lighter, two cans of soda, an umbrella, and the over-the-counter antihistamine Benadryl. Allen weighs each offer seriously and occasionally makes a deal. In the television room, a resident offers Sammy a three-quarters-full lighter in exchange for some of his soda. Allen lets him keep the lighter and pours him a cup. Another resident picks through the ashtrays looking for stubbed-out cigarettes to smoke. One man sits in a chair in the day room, points to different residents, and says, "See that guy over there? He's crazy."

Formerly a flophouse for alcoholics, Jefferson House is a privately owned boarding house (or residential hotel) that only recently started taking in the mentally ill because they were easier to control and were less of a problem, according to a manager there.

The environment blends peer support (a resident looking for crack money will do the laundry of an elderly resident who receives a disability check) with a jailhouse mentality (homemade tattoos, gimme-a-cigarette demands to show who's in control, a lot of verbal violence and threats).

"This is a dumping ground," shrugs a Jefferson House manager. "They opened up the institutions, and people had nowhere to go. MHMR wants them in the community. These people in here are the lucky ones."

Allen alternately rages against the boarding home and worries that the "boss man" will throw him out. He makes futile efforts to clean and organize his area, but gets confused, distracted, and forgetful in the process. Nothing gets accomplished but a bit of shifting around. He flip-flops on whether he will take his medications and, from time to time, goes to the desk to ask the on-duty clerk for them.

"I'm not supposed to be dispensing, really," one of the desk clerks confides. "We can't really keep their medication for them, but we tell them it's for security. I'm probably not supposed to be giving it to him [Allen], but I don't think they'll [MHMR] mind."

The Texas Administrative Code governing the use of medications for patients receiving community-based mental health services states that to be qualified even to supervise the self-administration of medications, a person must receive a training course taught by a physician, registered nurse, or pharmacist that includes education on the effect a medication will have on a patient and what symptoms a medication is intended to address; on recognizing, managing, reporting, and documenting side effects, adverse reactions, and medication errors; and on the potential toxicity of medications. (None of the Jefferson House desk clerks has any such mental health training, admits a manager at the boarding home.)

According to Charline Stowers, manager of information services Long Term Care Regulatory, the division of the Texas Department of Human Services that licenses personal-care facilities (which are the more expensive step up from boarding homes), workers in boarding homes are not allowed to render any personal care beyond providing room, board, and laundry. "They [residents] can even be sick, as long as no one is caring for them."

She adds that a boarding house is not allowed to keep someone's medication for them and control access to it, dispense medication, or keep records of who takes what and when. Jefferson House does all of these things.

"There's some consumers that really can't handle their own medications, and somebody's got to do it," explains ACT team coordinator Jesse Valdez. "I don't know if it's legal or not, I'll be honest. There's no regulations to govern those boarding homes. We have no control over that, and I don't know of anyone who does. If they don't [dispense meds], then what happens? Does the client not take the medication? Does the medication get stolen? Do the medications get misused by either the consumer himself or other consumers?"

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