Layers of failure for mentally ill

My first assignment when I was in the Navy was as the electrical officer on a destroyer. I was in charge of a division of 14 electricians and interior communications specialists, the equipment they maintained and their living and working spaces.

I was no engineer or technician. I spent most of my time on the bridge or leading boarding teams. I wasn’t qualified to replace a fuse. So how was I supposed to be responsible for that division?

Almost every newly minted junior military officer grapples with this. Fortunately, there is a system. Every division has senior NCOs who do the direct supervising and technical training. But officers cannot rely on them alone. You have to go tour your spaces, regularly. Your spot-check maintenance, and verify maintenance records. You ask questions, ask your people to teach you the basics and look for obvious signs of problems, equipment damage or neglected upkeep. You get involved and get your hands dirty, and if you do it right, you are never caught off-guard by an outside inspector – or worse, a senior officer – finding out about a problem in your division before you do.

It is a shame that we have so few veterans in Nevada’s government. Some of our most vulnerable citizens may have been spared their deplorable living conditions.

When the legislative audit revealing that the state-funded living arrangements for many of our mentally ill population were “squalid” and “bleak,” the outrage was immediate. That’s great as far as it goes, but the indignation and finger-pointing by our elected officials was frankly just frustrating.

Why? Because none of these people should have been surprised.

Take Gov. Brian Sandoval’s reaction. He said, “I am incredibly disappointed with the Department of Health and Human Services and disturbed that an issue we had made a priority has not been addressed by the Department.”

I think Sandoval is one of the most fundamentally decent human beings in politics. I don’t for a second doubt his sincerity in wanting this problem “fixed,” and I recognize he must rely on others to implement his policies. Nonetheless, the reality is that this issue wasn’t a priority of the governor. He says it was. He helped pass a law. But he didn’t visit any of the homes in question himself. He didn’t verify that maintenance or health records were accurate, or even kept. He didn’t speak to the tenants of the roach infested units. He didn’t “walk his spaces,” as we would have said in the Navy.

Instead, he signed a bill requiring more certifications and inspections, and then left the work of implementation to bureaucrats many layers removed from his office and let the matter fall from his radar, while devoting his personal attention and time to other things.

The same is true of every politician in both parties now expressing their outrage. None of them followed up, either. Priorities aren’t about what you declare in a press release, they’re about what you spend your time on. And the indigent mentally ill were simply not anyone’s priority.

This isn’t to say that fingers don’t need to be pointed – they do. But they should at least be pointed accurately. For example, Democratic Assemblywoman Maggie Carlton pronounced, “This shows to me that privatization sucks.”

There is certainly a good argument to be made that housing the profoundly mentally ill is not something a for-profit business is ideally suited to handle. But Carlton’s comment shows to me that she didn’t read – or at least understand – the report. Consider, on pages 20-21:

Although the Division developed policies and procedures to inspect provider homes, staff implementation of procedures is inadequate. For example, for 12 of 37 homes we inspected, agency staff performed home inspections within 5 days of our inspections and did not document most of the deficiencies we observed. Our inspections identified 140 items that did not comply with the agencies’ inspection checklists; whereas, agency inspectors identified 28 items.

In other words, the government employees specifically tasked with oversight of the privately operated homes actively ignored and refused to document readily apparent squalor, or they lied about conducting the inspections at all. The private providers of this “care” have much to answer for (criminally, even), but their government overseers Ms. Carlton apparently would replace them with are every bit as responsible and culpable for this revolting state of neglect.

When the government agent directly responsible for this oversight, Amy Roukie (who was forced out last week), tells legislators that the revelations in the audit were, “as shocking to us as they were to the committee,” it’s probably time to throttle back on one’s faith in the boundless competence of the government to solve all of life’s problems.

It is never enough for government officials, elected or otherwise, to mean well, or even to propose solutions. They must successfully execute those plans, constantly following through to ensure that their policies are being implemented competently. The larger or more distant our government is, or the more things government attempts to take on, the more difficult this will always be.

It is appropriate for our elected officials to be outraged at this maltreatment. But we’ve been outraged before, and nothing has changed. If we don’t want to be “surprised” again next year, lawmakers and bureaucrats alike must stay focused and engaged on this issue, even when the media spotlights inevitably move on.

Orrin Johnson has been writing and commenting on Nevada and national politics since 2007. He started with an independent blog, First Principles, and was a regular columnist for the Reno Gazette-Journal from 2015-2016. By day, he is a deputy district attorney for Carson City. His opinions here are his own. Follow him on Twitter @orrinjohnson, or contact him at