RALEIGH — In the past two years, at least four residents of North Carolina rest homes have been killed by fellow patients who had histories of severe mental illness and violence.

Nearly a decade after the state closed thousands of beds in government-run psychiatric hospitals, more than 6,400 people with severe mental illness are housed in adult care homes and assisted living facilities scattered across North Carolina, according to a state study completed this year. The mental patients, their care typically paid for with taxpayer money, are often far younger than the elderly residents with whom they are housed.

The advocacy group Disability Rights North Carolina filed a complaint with the U.S. Justice Department on Monday that contends the state is in violation of the Americans With Disabilities Act for failing to provide proper housing for people with mental illness and failing to police the sometimes squalid and dangerous conditions in these homes, which are licensed and inspected by the state.

The state estimates that about a quarter of all patients in the 627 adult care homes across North Carolina have a primary diagnosis of mental illness.

Lanier Cansler, the state's secretary for Health and Human Services, said Tuesday that if mentally ill patients weren't housed in rest homes, many would be on the street.

"There is obviously an issue with having the resources to do all the things we need to do," Cansler said. "We've not yet been given the authority to print money at DHHS. You can do everything you can to be efficient and effective with the way you use the available funds, but you can only stretch the dollars so far."

The explosion of mental patients in rest homes is an unintended result of a 1999 U.S. Supreme Court ruling that mandated that people be cared for in their home communities whenever possible, rather than being institutionalized in big state hospitals. As part of a 2001 effort aimed at complying with the ruling, North Carolina downsized its state-run psychiatric hospitals and disbanded county-run mental health agencies in favor of a plan to treat patients through a network of private, for-profit companies.

Money spent elsewhere

The money budgeted for building up the network of private care providers was soon diverted to other needs, and rest homes, traditionally used in North Carolina to care for elderly patients, began accepting increasing numbers of younger patients who would have previously been confined to psychiatric hospitals.

"Long-term care facilities have been an unavoidable choice for many individuals with mental illness," said a state study from 2005, "despite the fact that these facilities were not designed to provide psychiatric treatment or rehabilitative services to allow people with mental illnesses, particularly younger adults, to achieve a greater measure of independence."

At least four state-funded studies in the last five years have chronicled the problem and made detailed recommendations for addressing it, but few of those suggestions have been implemented.

Reports from homes

In May, investigators at Disability Rights teamed with students from the UNC School of Law to visit 15 adult care homes where the majority of residents have been diagnosed with mental illnesses.

Their report describes mentally ill patients warehoused in poor conditions, sometimes "parked" in wheelchairs and so sedated that their pupils were dilated and drool dripped from their mouths. Some patients interviewed as part of the survey described abuse and neglect by staff, while the students observed problems such as infestations of flies and gaping holes in the walls.

The facilities were often understaffed. State regulations require only one worker for up to 25 patients during the night shift, far less than the one to six ratio required at a facility specifically licensed to treat the mentally ill.

"The conditions in some of the homes were deplorable," Smith said. "We hope the involvement of the Department of Justice will make providing services to this population a higher priority."

Cansler said supervising the quality of care provided to patients in rest homes is already a priority but there are limits to what his department can do.

"We really need a better system," Cansler said. "With the staff we have, we do well to visit these facilities annually, unless a complaint is filed."

michael.biesecker@newsobserver.com or 919-829-4698