"There is huge corroboration," Lipman said in an interview. "We're not sending people [to Spring Grove] just because Judge Lipman says, 'Oh, he should go.' They are seen by screeners who are paid by the Department of Health and Mental Hygiene."

Appelbaum referred all questions about his report to health department officials.

Dr. Gayle Jordan-Randolph, the health department's director of forensic services, acknowledged the agency's role in many of the problems that arise at the judicial level. She said in an interview that she has ordered new training for all department staff involved in evaluating and placing forensic patients.

The department is also revamping its data system for tracking patients' commitment schedules, court dates and treatment, and has launched a new quality management committee to review security protocols at Spring Grove and state-run Springfield Hospital Center in Sykesville, a hospital that Appelbaum's report touches on. Officials are also trying to increase communication with local state's attorneys' offices.

Other reviews are under way — started after Appelbaum's December 2012 review of Perkins — to address procedures for managing aggression and violence among patients at facilities across the state, Jordan-Randolph said. Assaults have been trending down for years, she said.

In the 12-month period ending in September, there were 83 assaults on Spring Grove staff, including the 66 that required medical attention, according to the StateStat database. Nine patients were assaulted over that period. Staff members were granted more than 2,000 hours of leave because of their injuries.

Staff and patient safety is the department's top priority, Jordan-Randolph said, but "understanding the factors at play in that is a moving target every single day."

That comes as little consolation to staff members at Spring Grove and Springfield, who said they — and the more vulnerable patients they work with — are the actual moving targets.

"I wear tennis shoes to work so I can run," said one Spring Grove staff member, who spoke on the condition of anonymity for fear of losing her job.

The employee, who regularly interacts with forensic patients ordered to Spring Grove by the courts, said she has been randomly punched in the face, kicked, spat on and bloodied. "Honestly, I don't know anyone who hasn't been assaulted," she said.

Most of the assaults come from patients who the hospital's clinical staff believe are faking their symptoms, she said.

"Those are the individuals that scare you when you walk in, because they don't necessarily have a mental illness that's dictating their behavior," she said. "Those are the patients who should be in jail. I wouldn't even really call them patients."

Spring Grove has its own police force, but the Maryland State Police also responds to the hospital campus for higher-level crimes, and did so nearly 50 times in the past two years — for reports of thefts, assaults, rapes, escapes and suspicious deaths. In early 2012, a patient was stabbed, according to state police records. That year, troopers responded to the hospital for 12 escapes, as well as two alleged sexual assaults and two deaths.

Moran said AFSCME is backing legislation in the current General Assembly session that would create a "Workplace Violence Prevention Program" for health care facilities and require more standardized reporting of assaults in hospital settings.

Jordan-Randolph said the health department is reviewing all reporting protocols. She also said that moving patients who shouldn't be in the facility more rapidly through the system, and improving court-level evaluations so fewer of them are admitted in the first place, will be critical in further decreasing assaults.

"If we find that a person does not have a mental illness, is in fact faking a mental illness, then we should have the ability to move that person back to court," she said. A single patient, she said, can "disrupt the safety of a unit, the safety of a hospital."