James Brown, who has been diagnosed with psychosis, spent three days at Rawson-Neal Psychiatric Hospital, in Las Vegas, in February 2012. Depressed and thinking of suicide, Brown ended up there after problems at his group home.
But just three days after he was admitted, the doctors felt James was stable enough to go.
Then, Brown says the doctor asked him what state he wanted to go to.
"I said, 'I don't want to leave Nevada,'" Brown told ABC News. "He said, 'California sounds like a really nice state. I think you'll be happy there.'"
Although Brown had never been to Sacramento, he says he was told he would get better mental health care there. Brown was driven to a Greyhound bus station with a $306 one-way bus ticket, six Ensure nutrition shake bottles and just a three-day supply of psychiatric medications.
Brown's discharge papers even listed his "address on discharge" as "Greyhound Bus Station to California." He says he was told to call 911 when he arrived in Sacramento – around the same time he would run out of pills to treat his mental illness.
"If I don't take my medicine, I get really confused and I start hearing voices in my head, and they tell me to, like, jump off a bridge or to do something to purposefully get arrested or go to prison or jail," he said.
After a 16-hour overnight Greyhound bus trip, James arrived in Sacramento, but he didn't call 911. So instead, a confused Brown walked to a nearby police station- the police took him to a homeless shelter. By then, he was feeling the symptoms of medication withdrawal: a headache, profuse sweating and confusion.
He had no Social Security card, no food stamp card and no Medicaid card.
The Sacramento Bee first broke Brown's story last month, finding Nevada has purchased nearly 1,500 bus tickets since 2008, sending patients by bus to every state in the continental United States, mostly California.
With Brown's permission, ABC News obtained and reviewed his entire Rawson-Neal medical record. Documentation in the medical record shows his most clear wish regarding his discharge from Rawson-Neal was to go to a local group home.
In fact, there is clear documentation in the medical record that the hospital, just the day before discharge, did not plan on sending him out of state.
ABC News also reviewed medical records, bus receipts and six years' worth of hospital error reports.
Brown's case has prompted Nevada to review decisions to bus the nearly 1,500 mentally ill patients out of state.
Mike Willden, who directs Nevada's Department of Health and Human Services, told ABC News that the busing policy has existed for about 30 years. He said an internal review lasting two weeks found that only 10 of the nearly 1,500 bused patients were bused inappropriately.
Still, Nevada Gov. Brian Sandoval announced on Monday that the state had disciplined mental health employees as a result of the review. In an email to ABC News yesterday, the state confirmed there were nine different Rawson-Neal medical staff members responsible for the discharge plans in question. Four of these staff members are no longer employed with Rawson-Neal and of the remaining five, two were terminated and three are subject to further disciplinary action.
The hospital has also changed its policy and will now require chaperones for all bus trips.
Willden said the term "patient dumping" offends him, because the hospital was mostly helping patients get home to their families.
Although the cases they found in which the patients were sent out of state without following protocol were "serious," Willden said it was not "systemic."
A former Rawson-Neal employee, who spoke exclusively to ABC News on condition of anonymity, said he saw several patients bused out of state before they were ready to be discharged.
"There was this one female patient who was not stable at all," he said. "So she was drooling, stuttering, she's not able to communicate with us, she's lost in limbo. She's floating."
Another patient was discharged right after threatening this employee, he said.
The former employee says he reported his concerns to a nurse, but was told the doctor's decision on discharging patients was the final word.
In an interview, when ABC's Cecilia Vega asked Wilden where the rest of the 10 patients found to be bused inappropriately wound up, he refused to answer.
"I don't think it's appropriate at this time," he said.
He added that other states bus mentally ill patients to Nevada.
"I'm not saying it's right," he said. "I'm saying it happens."
The American Psychiatric Association said, "It's an unfortunate reality that most state and local mental health facilities are facing critical funding shortfalls, and this may be contributing to efforts to relocate patients to communities where they live and help is available and has been arranged."
Dr. James Scully, medical director and CEO of the American Psychiatric Association said, "We call upon the authorities to investigate whether patients are indeed receiving the care and support they need, supplied by facilities with adequate space and funding for the patients they serve."
Fortunately for Brown, a counselor and a Sacramento Bee reporter helped him connect with his daughter on the East Coast.
"I don't want revenge, and I don't know about justice, but I want them to pay for what they've done to me and the others," Brown said. "I want people to really take a moment to think about this."