Safety at Atascadero State Hospital is questioned by some employees

Tribune photo by David Middlecamp

Courtney Forzetting loved helping people. As a psychiatric technician at Atascadero State Hospital, she enjoyed using her skills to assist the mentally ill. Her 10-year career left her fulfilled.

All that was shattered in 2008 when one of her patients, agitated and taking different medication under new federal rules, pounded the back of her head over and over with his fist. She struggled to stay conscious.

“I kept thinking, ‘Stay standing. Stay standing. Stay standing,’ ” Forzetting said, afraid that if she went down, the man would bash her head in with his foot. She lost count of the blows before staff intervened.

In 2010, Forzetting settled a workers’ compensation case and was diagnosed with posttraumatic stress disorder. She has tried three times to return to ASH but couldn’t because she was unable to overcome her fear.

Ever since the attack, the 39-year-old hasn’t slept a full night. Now she always finds where the exits are in a building. Tight spaces ignite panic.

“I’m constantly afraid someone is going to get me,” she said. “Emotionally, I’ll never be the same.”

Forzetting blames extensive federal regulations that took effect in 2006 as a key factor in her attack.

Those regulations — designed in part to protect patients’ civil rights — restricted when and how often ASH employees can use medications and restraints to calm patients on the spot.

In Forzetting’s case, she said her attacker was taken off “the only drug that kept him from wanting to hurt people” because it made him unable to control his bladder. Federal regulators consider bladder control a civil right.

Staff members and the unions representing medical personnel at ASH claim that violence overall has increased since 2006, when the regulations took effect. Hospital workers, who said that they’re already under pressure due to increased patient loads and inadequate staffing, argue these and a series of other issues have made the institution a more violent and dangerous place for everyone.

Hospital statistics appear to support that contention. Staff injuries related to aggression have generally increased in recent years — 98 in 2005, 74 in 2006, 84 in 2007, 105 in 2008 and 135 in 2009. Comparable statistics for 2010 weren’t yet available, but 100 such injuries were reported through Sept. 11.

In response, ASH administrators said that many of the issues staff had complained about are a result of increased admissions, rather than new rules or staffing shortages. The hospital is run with legal staffing minimums, administrators said, though they are seeking permission from the state to hire more personnel in the admission units.

Administrators acknowledged that there has been a spike in aggressive behavior in the past three years, but said that overall the number of injuries requiring more than first aid has not risen during that time span.

Changing rules

ASH patients represent a wide swath of people — from inmates on psychotic breaks sent from prison to others deemed mentally unstable waiting for trial.

The new federal rules — known as the enhancement plan — limit the use of seclusion, restraints and psychotropic medications on patients so their basic human rights are upheld. The program stemmed from a 2006 settlement between the state Department of Mental Health and the U.S. Department of Justice.

The Justice Department alleged patients were being treated unfairly at four of the five state hospitals, including ASH, and after much discussion state officials said they would change how things were done.

DOJ did not tell the state why it began the investigations or what kind of wrongdoing was alleged. Coalinga State Hospital wasn’t included because it wasn’t yet built when the investigation took place. Under terms of the settlement, the state was told to first offer alternatives to patients who were about to become violent before restraining them.

That meant instead of offering on-the-spot medications or restraints to calm them, staff had to first present an alternative. That included taking a walk outside or offering a snack, for instance. As a result of the settlement, there were also changes to the long-term medications patients could take to manage their symptoms.

“I had patients coming up (to me) saying ‘I need to go into restraints because the voices in my head are telling me to hurt you,’ ” Forzetting said. “And (federal regulators) wanted me to offer him a cookie.”

Before, patients could be restrained with wrist, ankle and chest straps and be given a psychotropic drug whenever staff saw fit, ASH Executive Director Jon DeMorales said. ASH never used straitjackets, he said.

Seven employees who spoke with The Tribune said the enhancement plan isn’t right for ASH. Despite its positives, it places severe limits on how to protect hostile patients from themselves and others.

“You have mentally ill patients that frequently become agitated and angry, and escalate more frequently because they are undermedicated,” one employee said.

The employees didn’t disclose their names, length of employment or positions because hospital rules forbid them from talking to the media.

DeMorales said he would like to change some aspects of the plan but declined to give specifics.

Employees said the plan also has added administrative duties that create more stress and unneeded distraction.

In 2008, the program ramped up caseload documentation so the hospital pulled nurses and psychiatric technicians to fill out paperwork, DeMorales said.

That’s when unit supervisors began filling the gaps on the treatment teams.

“What tends to happen is (employees) are more treating the documentation and the charts over the patient,” one employee said.

Violence and crimes

October’s killing of Donna Gross, a psychiatric technician at Napa State Hospital, who was strangled by a patient in an outside courtyard, has shaken many ASH employees.

They’re concerned that staff injuries related to aggression have increased in the past three years. Aggressive behavior includes punching, pushing, yelling profanity and fighting.

According to records obtained by The Tribune, patients have lunged at staffers as well as charged, grabbed and slapped them. In one case, a patient repeatedly hit a staffer with a pillowcase packed with books, according to the data.

“The bottom line is that’s the nature of the people we treat,” DeMorales said of patient aggression. “We don’t ignore it. We’re constantly watching it. But it will always be there.”

Besides an increase in staff injuries related to aggression, there has also been an increase in patient arrests for misdemeanors and felonies committed inside ASH.

Last year through Sept. 1, there were 16 arrests. Even though eight of those were for one incident Aug. 31, that total is for only two-thirds of a year. By comparison, the number of arrests was four in 2005, three in 2006, seven in 2007, 10 in 2008 and eight in 2009.

When patients commit crimes inside the hospital they are treated like anyone would be for committing a similar crime on the outside.

Administrators track violence daily, officials said, looking for patterns and changes to help determine the causes.

About two years ago, the hospital saw more aggression from patients throwing objects. As a result, they installed heavier furniture and violent acts decreased.

Last spring, administrators saw a spike in aggression in the evening hours and found that patients became more agitated while congregating in day and meal rooms.

So, more planned events were added — such as movies and bingo tournaments — to help bring more structure into the downtime. Administrators said it helped.

Staff feels overwhelmed

Despite their mounting worries, many employees said they remain at ASH because it pays well and they enjoy their work. The hospital is one of San Luis Obispo County’s top employers, with more than 2,000 workers.

Psychiatric technicians can make up to about $60,000 annually while psychiatrists can earn up to about $256,000 a year.

Still, employees contend they are overworked and overwhelmed. Employees said they are increasingly calling in sick because they are becoming worn out by working overtime shifts mandated up to six times per month and up to two times per week.

“If you are exhausted, (that affects) any job, let alone working with mentally ill criminals,” one employee said.

Another staffer said calling in sick is a “vicious cycle” because it’s almost unavoidable and prompts the need for another staffer to go on mandatory overtime to fill the gap.

Monthly ASH admission rates saw major spikes for several months as dozens of new patients arrived after mandates in June 2009 and May 2010. The mandates put pressure on state hospitals to reduce waiting lists for inmates on psychotic breaks or offenders deemed incompetent to stand trial.

DeMorales said the weekly pace of admissions in the past few years has become the real problem.

It’s so rapid, patients are moved out of admission units and into the main wings of the hospital sooner than recommended. There isn’t enough staff to stabilize them before new influxes come in, he said. DeMorales said the state’s push to fill more beds leads to more hands-on time per patient because new patients take more time to adjust. Patients are most aggressive in their first 90 days at the facility, he added.

As a result, the hospital has asked the state to change the formula it uses to determine the patient- staff ratio; it’s now based on inmate numbers, not the amount of time it takes to admit them. If DeMorales succeeds, he will be able to adjust staffing in the admission units.

Solutions sought

ASH employee unions are slated to voice their safety concerns at an annual meeting planned for Monday at the hospital. The meeting is not open to the public.

At the state level, State Sen. Sam Blakeslee, R-San Luis Obispo, said he has been working over the past six years to address safety concerns at ASH.

“The recent murder of a psych tech at the Napa State Hospital highlights the risks that hospital staff are facing on a daily basis,’’ he wrote to The Tribune.

Blakeslee is developing legislation to protect staff from violent assaults by patients who can currently refuse the medications needed to stabilize their conditions. “My bill will empower state hospitals to administer medication to those patients who pose a threat to other patients and staff,” he wrote.

He’s also looking to reintroduce legislation to strengthen penalties for patients using human bodily fluids as a weapon, Blakeslee said, because that exposes employees to diseases such as hepatitis.

Nearly three years after her incident, Forzetting says she knows the struggles she once faced are still paramount inside the hospital.

“I would say that morale is at its all-time low right now,” she said.

A closer look at Atascadero State Hospital

Atascadero State Hospital is one of the highest-level security facilities among California’s five state hospitals, admitting everyone from murderers to those who have attempted escape. The facility’s all-male patients are referred from other state hospitals, superior courts and the Department of Corrections.

Sexually violent predators were also housed there until fall 2005, when they were moved to the newly constructed Coalinga State Hospital in Fresno County designed just for them.

Hospital staff work 24 hours a day to manage patients’ mental illnesses after they arrive. Medication, therapy and daily programs help stabilize them.

The patients include those incompetent to stand trial, those not guilty by reason of insanity or those on psychotic breaks transferred from prisons.

They’re discharged, on average within six months, back for trial or to prison.

Two other types of offenders at ASH are those who are so sick that they serve their parole time at ASH to receive more treatment and then are discharged into conditional release programs. The last is a group ultimately deemed too dangerous for society and stays at ASH after their parole has expired.

Timeline of Atascadero State Hospital regulations.

Treatment methods at Atascadero State Hospital have changed since it first opened in 1954. “Shifting public, professional and legislative attitudes on the relationship between crime and mental disorders” helped shape treatment methods over the years. Its initial policies were based on the belief that some deviances could be cured.

In the 1950s, ASH had less security than it does today. Its programs allowed for inmate choirs and bands to perform in nearby towns. Patients took field trips and nature walks. Some ran an onsite vegetable farm and swine unit that helped feed the hospital. However, such policies led to a rash of escapes and those procedures, along with the farm, ended in 1955.

In the 1960s ASH survived society’s belief that all state hospitals “should and would disappear.”

In the 1970s, legislation moved the hospital into specialized treatment approaches for individualized needs, rather than taking its former blanket approach to treatment. ASH did away with centralized medical and nursing services. In 1978, night shift employees alleged unsafe working conditions because patient rooms weren’t routinely locked at night. Reforms were enacted so they would return to work.

In the 1980s, federal agencies became increasingly involved with policy. Facility accreditation became a must in 1984 and was achieved in 1986. Officials got there by making changes to everything from procedure to the building itself. Fire and safety building codes were met and more office space was added.

In the 1990s, staff was trained to meet new goals so the facility could keep its accreditation. Sexually violent predators arrived in 1996. They left in 2005 after several patients filed lawsuits alleging they didn’t belong at ASH because they were not mentally ill. ASH staff struggled to treat them because these men were described as manipulative and acted outside the parameters of their training. The SVPs were moved to a new hospital in Colinga, in Fresno County, designed specifically for them.

In the last decade, ASH struggled with state budget cuts and tried to keep its employee base steady.

In 2005, unions said ASH struggled to fill more than 100 nursing and psychological technician positions in addition to 12 psychiatrist jobs.

In 2006, the labor groups complained about low pay. The following year, more than 1,200 workers received pay increases.

Source: ASH documents and Tribune archives