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.