Violence at state hospitals spurs calls for change

Violence at state hospitals spurs calls for change

Among proposals are high-security units for the most predatory patients and expedited hearings to involuntarily medicate the violent. With most patients having committed crimes, 'you have to be somewhere between a hospital and a prison,' a union official says.

By Lee Romney, Los Angeles Times
January 1, 2011
Reporting from San Francisco

For years, the number of patients in the state's mental hospitals who have committed crimes has been rising. Today, they represent more than 90% of the population.

That dramatic trend has brought an increasing level of violence to the hospitals, including vicious attacks on patients and hospital employees.‬‪ As assaults rose, staff members privately urged state officials to improve security at the hospitals to no avail, documents show.

But the slaying of a Napa State Hospital psychiatric technician two months ago has emboldened angry employees to go public with their demands.‬‪ The outcry has captured the attention of at least three state lawmakers who plan to press for significant changes.

Two of them toured Napa's aging campus last week and have called on incoming Gov. Jerry Brown "to immediately allocate the necessary resources to secure the hospital."‬‪ The third, state Sen. Sam Blakeslee (R- San Luis Obispo), has met numerous times over the years with employees at Atascadero State Hospital and said he was shocked by the rising degree of danger.

"This level of violence is unacceptable," he said.‬‪

The unions that represent hospital employees are working together to craft legislation that calls for high-security units at each hospital to house the most predatory patients, expedited hearings to involuntarily medicate those who are violent and a streamlined process to transfer dangerous criminals sent for treatment by the corrections system back to prison.‬‪

More fundamentally, the violence is spurring a debate on the viability of the mental hospital system's core philosophy — to maintain a treatment environment that does not resemble prison.‬‪

"The days when Grandpa's a little crazy and ended up at Napa State Hospital for a while, those days are gone," said Brad Leggs, the facility president for the California Assn. of Psychiatric Technicians. "Now we have a barbed wire fence up and we have police officers guarding the perimeter. There's a prison mentality."

Although it's essential to "keep the treatment in place," Leggs said, "you have to be somewhere between a hospital and a prison."

‬‪Blakeslee agrees.

"There needs to be capacity to handle patients who are not completely right for a pure corrections system or a pure therapeutic setting," he said.‬‪

The debate comes as some clinicians question the use of cages at the California Medical Facility at Vacaville, northeast of San Francisco, to restrict the movement of dangerous mentally ill prisoners during therapy sessions.

The state mental hospitals have already moved toward more patient freedoms. Even as they receive more patients from prison who are too sick to be treated there or can't be accommodated, hospital police remain unarmed and don't visit units unless called in a crisis‬‪.

The hospitals have been subject to a federal court judgment to improve care since 2006.

But a review of data through mid-2010 shows overall increases in patient and staff assaults at the four facilities under federal monitoring. In addition to Atascadero and Napa, those include Metropolitan State Hospital in Norwalk and Patton State Hospital in San Bernardino.

‬‪In the mid-1990s, four-fifths of the patients were committed by the civil courts. At Napa, they wore their own clothes and went on outings to see the city's Christmas lights. Today, more than 90% of patients are there because they committed crimes.

Many arrive with gang affiliations, hard-to-treat antisocial personality disorders and predatory behavior, staff and mental health officials say.‬‪ The rise in violence at Napa has been particularly acute.

Attacks on staff in the second quarter of 2010 doubled to about 200 compared with the same period of 2009, and patient assaults against one another soared about sixfold to 692, state data show. The hospital's buildings, some from the 1800s, are scattered across a bucolic campus in a rambling way that makes control difficult.

Dr. Richard Frishman, a Napa State Hospital psychiatrist, works in an office that is tucked out of sight. In 2008, he was beaten by a patient, his wrist broken and his eye blackened.

"I never know if the next time I walk out of my office it's going to be my last," he said.‬‪ The alarm carried by a colleague who was with Fishman failed to go off.

Staffers have called for an improved system. The current one does not work outdoors, where 54-year-old Donna Gross, the first staff member killed in the hospital system in two decades, was strangled.‬‪

Staff members stress that patients are victimized more often than staff.

"We believe you can't possibly treat an individual who is highly aggressive without sufficient security enhancements," said Dr. Patricia Tyler, a psychiatrist at Napa who is working on behalf of the Union of American Physicians and Dentists to help design proposed fixes to the system.

‪Key among them is a high-security unit at each hospital that would place the most predatory patients in a more rigid environment with specially trained staff and a regular officer presence.

Documents show that a unit was retrofitted for that purpose at Napa in 2006 and had the approval of hospital management, but was derailed in part over a labor dispute.‬‪ Another proposal would require that hearing officers come to the hospitals within 72 hours to decide whether dangerous patients who arrive from jails as "incompetent to stand trial" can be medicated against their will.

The process now takes as long as three months, Tyler said.‬‪ Yet another proposal would make "gassing" of staff — the throwing of feces, urine or other bodily fluids — a felony. It is already a felony for state prisoners.‬‪

The federal consent judgment demanded a shift in treatment to what is known as a "recovery model," a patient-based form of care that has included a push to reduce the use of restraints, seclusion rooms, some medication cocktails and one-to-one supervision of patients.‬‪ Many staff members say the changes have been implemented in a way that has reduced safety, an allegation that administrators deny.

Although there are efforts to reward good behavior, attempts to withhold rewards because of bad behavior have been discouraged.‬‪

"A 3-year-old gets put in time out or grounded for a week. These guys don't get any consequences," said Kathleen Thomas-Morris, a nurse at Napa .‬

‪The Department of Mental Health, which runs the hospitals, has not taken a position on the proposals, said spokeswoman Jennifer Turner, but is "committed to providing technical assistance and working with legislators to understand the impact of the issues."‬‪

At Napa, administrators have withdrawn all patient grounds passes while reworking the system by which they are awarded. They are poised to implement a "grounds patrol" staffed by psychiatric technicians and are taking measures to clear some trees and shrubs, Turner said.‬‪

Staff memos have described extensive contraband activities and fights on the grounds.‬‪ Results of a security audit are expected soon, and Turner said hospital officials are meeting with employees and unions to gather suggestions before the next legislative budget session.‬‪

Blakeslee said he is committed to legislation calling for high-security units and making "gassing" a felony. State Sen. Noreen Evans (D-Santa Rosa) and Assemblyman Michael Allen (D-Santa Rosa), who recently visited Napa, are talking to employee groups.

"One thing I take very seriously is my responsibility for oversight," Evans said.‬‪ Allen, a onetime psychiatric nurse, has called for immediate fixes, including more fencing and video cameras.

The freshman lawmaker, who landed on the budget committee, hopes to take the members of the panel and the new governor on a tour of the facility.

"We have a bad budget situation," he said, "but when you have people being killed, people being harmed, that's not a savings."

lee.romney@latimes.com

Times staff writer John Hoeffel contributed to this report.