By Kevin Rector, The Baltimore Sun
9:02 PM EST, March 2, 2013
In-patient units at Spring Grove Hospital Center in Catonsville have become troubled environments where serious assaults on hospital staff are common, according to a scathing new report from a consultant for the Maryland health department.
The chaos at the state's largest psychiatric hospital, the consultant found, is fueled by a few patients who "prey upon patients and staff with relative impunity" after being ordered by courts to the hospital for psychiatric evaluation — sometimes with dubious symptoms.
The findings are contained in a report created for the Department of Health and Mental Hygiene in response to safety complaints from hospital staff. The report by Dr. Kenneth Appelbaum, an expert in forensic psychiatry at the University of Massachusetts Medical School, describes a number of violent incidents over the past year. It also highlights an ongoing dispute between judges and clinicians over patient admission standards.
In one incident, a man who told court officials that "voices told him to sell the drugs" he'd been charged with distributing — but who doctors determined was faking mental illness — set fire to his room with a contraband lighter in an attempt to escape, the report said. In another, a nurse was hospitalized "after sustaining blows to the face and head" from a patient whose court-ordered admission was also questioned by clinical staff.
State health officials said problems described in the report are well-identified and are being addressed. According to state statistics, in a recent 12-month period ending in September, there were 66 assaults on Spring Grove staff that required medical attention.
But hospital employees and leaders of the American Federation of State, County and Municipal Employees local said more needs to be done.
Denise Gilmore, an AFSCME staff representative, said assaults occur frequently at Spring Grove and sometimes go unreported. "It's the idea that an assault can occur and there's nothing you can do to ensure any consequences," she said.
Appelbaum's report also found problems in how the health department staffs the hospital, how emergency calls for security during attacks are responded to, and how staff communicate with superiors and one another.
A draft report marked "confidential" described in-patient units as "lawless environments," but that language is not in the final version of the report, according to health department spokeswoman Dori Henry. She said Appelbaum "edited the language after further reflection and feedback on his first draft from a variety of people, including Spring Grove staff."
Much of Appelbaum's report focused on the judicial system.
"The apparent ability of Maryland courts to keep dangerous criminal offenders for prolonged periods in state hospitals in the absence of clinical justification for hospitalization accounts for most of this excessive risk," wrote Appelbaum, who previously reviewed Clifton T. Perkins Hospital, the state's only maximum-security psychiatric hospital, after deaths occurred there.
Appelbaum wrote that he found examples of patients who were faking mental illness and recovered patients who were not being returned to court quickly enough. He also cited instances in which patients were kept at Spring Grove longer than the legal terms of their commitment because the courts were not happy with the post-commitment, community-based services the health department had arranged.
"Some defendants probably spend more time committed as [incompetent to stand trial] than they would spend incarcerated if convicted of their crimes, and certainly more time confined in the hospital than they would if civilly committed," Appelbaum wrote. "Instead of a supportive role to improve patient adherence to treatment plans designed by treatment professionals, the Court often designs its own treatment plan for clinical professionals to follow."
Patrick Moran, president of the local AFSCME chapter, said judges and others in the judicial system have overstepped their bounds when it comes to the treatment of mental health patients at state facilities. "They're acting as the clinical professionals and the legal professionals, where, in our opinion, they have no authority to act as the clinical professionals."
Advocacy and watchdog groups have long questioned how Maryland courts handle defendants found incompetent to stand trial or not criminally responsible for their crimes. A 2004 lawsuit filed by the Maryland Disability Law Center forced the state to amend its laws to limit when and for how long a court can order a patient admitted into a state psychiatric facility.
In 2011, a report by the Justice Policy Institute said that between 2006 and 2011, the number of patients admitted to Spring Grove after being found incompetent to stand trial had increased by 335 percent, and that hospital admissions were being used by judges as "de facto punishment for a crime in which the person was never tried and convicted."
Court officials, however, have defended their actions. This week, they called Appelbaum's report — which was obtained by The Baltimore Sun before its release — a poorly sourced document of "bald allegations" based on little data and serious misunderstandings of judges' legal responsibilities.
In a Feb. 26 memorandum in response to a working draft of the report, the Maryland Judicial Conference Committee on Mental Health, Alcoholism and Addictions wrote that Spring Grove is often "the only secure placement that is legally available to trial courts" and "should have the capability to house and safely manage many potentially assaultive patients" who by law cannot be placed in prison.
Health officials are regularly involved when decisions about defendants are made, the judges wrote, and although there may be individual cases where defendants are held in facilities longer than might be appropriate, the problems are not based on court failures.
The majority of court mental health findings — determined in consultation with DHMH-appointed court evaluators — align with more extensive clinical reviews of those individuals once they arrive at a facility like Spring Grove, said District Judge George Lipman, chair of the committee.
"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."
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