In the early-morning hours of Thanksgiving Day, Catherine Starkes and April Savage huddled in an office with several other employees at the Springfield Hospital Center in Carroll County as patients rioted around them.
Starkes and Savage said patients threw chairs, knocked over file cabinets and tried to break into the staff's Plexiglas-enclosed refuge. The patients poured cooking oil over the floors, making them slippery. One patient tried to crawl into the office through the suspended ceiling, Starkes recalled.
It was like no other night she could remember in 22 years of working with dangerously mentally ill patients at Maryland state hospitals.
"They wanted to take over the unit. They seized the unit," she said.
Workers in state hospitals and their union say the incident is only the most recent illustration of the dangers state employees face in Maryland health facilities. They say that many of the facilities are chronically understaffed and that staff members are ill-equipped and inadequately trained to deal with an increasingly dangerous population.
The state Department of Health and Mental Hygiene, which operates Springfield and other state psychiatric facilities, says 90 percent of patients in its facilities are referred by the criminal justice system, up from 38 percent 15 years ago.
Patrick Moran, who leads the largest union representing workers at state mental hospitals, said hospital staff are assaulted "on a frequent basis." He said that the severity of the incident last month was unusual but that workers at these hospitals are often at risk.
"There's insufficient training for the type of clientele that the hospitals are overseeing now," said Moran, president of a local council of the American Federation of State, County and Municipal Employees.
The Springfield riot is the latest in a number of violent incidents at Maryland psychiatric hospitals. In 2013, a consultant for the state health department documented serious assaults on hospital staff members at the Spring Grove Hospital Center in Catonsville, and two patients were killed by fellow patients at the Clifton T. Perkins Hospital Center in Jessup in just over a year between 2010 and 2011.
The department delivered to the General Assembly a report on security at the state's psychiatric facilities the week before Thanksgiving. The report said the department is "currently addressing providing police and security with the right equipment and training them to implement best practices."
The report, signed by Health Secretary Van T. Mitchell, noted that officials at six of the department's seven psychiatric facilities said they need more security personnel. It also noted that it is difficult to attract applicants for the positions and that turnover is high.
Still, Christopher Garrett, a spokesman for the health department, said staffing across the agency is adequate and based on set ratios of workers to patients, which are often determined by federal guidelines.
State police, health department officials and staff members at the Springfield Hospital Center described in interviews with The Baltimore Sun what happened on Thanksgiving in the Secure Evaluation Therapeutic Treatment center in the Muncie Building at the Sykesville hospital campus.
The unit, which is separate from the rest of the Springfield complex, evaluates and treats patients who have been referred by courts as either not criminally responsible for their actions or mentally incompetent to stand trial. Springfield Hospital Center has an annual budget of $73.4 million.
After the incident, three patients were arrested. One was charged with "inciting a riot." That patient and one other were charged with assault, reckless endangerment and malicious destruction of property. A third was charged with disorderly conduct and resisting arrest.
Garrett said that two staffer members were hurt in the incident, though he declined to provide details, citing privacy concerns. He disputed that understaffing led to the riot.
"Despite having a significant number of staff on leave/holiday," Garrett said in an email, the therapeutic treatment unit "was fully staffed across all shifts."
The Developmental Disabilities Administration, a division of the health department that operates the unit, plans to provide staff with two-way radios and to research how "personal alarm transmitters" could be used there. The devices can be used to summon security.
Garrett also said a health and safety officer with the administration and the department's police chief will review the physical plant for possible changes and will develop procedures to deal with new disturbances.
Staff members said they were under siege for about five hours during the incident, as officers from four police agencies surrounded the facility shortly after the riot erupted.
Then, at 4:30 a.m., a Maryland State Police SWAT team entered the unit and freed nine patient care and security workers who had locked themselves in three offices. Savage, the shift leader on duty that night, still wonders why she and her colleagues had to wait so long.
"I don't know why they didn't come in as soon as they got to the building," she said.
Garrett said when state troopers initially went to the door of the building, they were "met by patients inside who indicated they were ready to fight with police." The troopers backed off and called for the SWAT team, he said.
State Police spokesman Greg Shipley said troopers took their time to determine the layout of the building, consult with the hospital administration and develop a plan of action. Because they were receiving information from staff inside the office, they were prepared for the oil-soaked floors, he said.
Shipley said it is "very rare" that troopers are called out to quell a disturbance at a state mental hospital. "I can't remember the last time that's happened," he said.
A nine-year veteran at the unit, Savage said she too had never seen such a serious disturbance.
As the staff took refuge, Savage said, patients scattered seasoning from the kitchen through the ceiling into the staff office, making it hard to breathe. She said they also tore down video cameras mounted in the unit and assaulted two male staff members.
Savage said the rioting involved about 10 of nearly 30 patients in the unit. She said it died down as some patients drifted off to bed.
Garrett said the SWAT team entered the building with a key provided by staff and scattered a gritty substance on the floor to prevent slipping. He did not disclose how many staff members were working at the time, saying that the incident happened over two shifts.
"Some staff were able to exit the shift while others were permitted onto the shift as the incident escalated," he said. "When the police responded, any staff outside were not allowed to enter."
He also said the department does not yet have an estimate of the cost of the damage.
Starkes and seven other employees at state mental facilities gathered at an AFSCME office in Baltimore a week after the incident to discuss workplace security issues. They stressed that they were speaking as AFSCME members and not for the department. They did not discuss the actions of individual patients.
The employees said only Clifton T. Perkins Hospital Center is adequately prepared to treat violently inclined, mentally ill patients. Perkins is the state's only maximum-security mental health facility.
Lisa McKinney, a licensed practical nurse at Perkins, said such a major disturbance likely wouldn't happen there. She said 10 to 15 security personnel are poised to respond immediately if an incident occurs.
Stephanie Daniels, a security attendant at Perkins, said she and her peers are sent to the same training academy as police officers and corrections officers. She said attendants at Perkins are well-trained in holds and restraints. And employees there are equipped with personal alarm transmitters.
Employees at the department's other facilities, including Springfield and Spring Grove Hospital Center in the Baltimore region, say they have not been issued such alarms and do not have comparably trained security attendants.
They say they lack the staffing, equipment and training to deal with the growing number of so-called "forensic" cases — patients sent to state hospitals by the courts — that Perkins can't accommodate.
The consultant hired three years ago by the department to look at conditions at Spring Grove described problems with staffing, emergency responses and internal communications.
Dr. Kenneth Appelbaum, an expert in forensic psychiatry at the University of Massachusetts Medical School who compiled the report, said violence at the hospital was being driven by a few court-referred patients who "prey upon patients and staff with relative impunity."
When the two patients were killed at Perkins, mental health advocates and union officials called for increased staffing and policy changes, and workers at Perkins sent a letter to department officials describing a climate of fear at the facility.
Patient assaults on staff members at the department's psychiatric facilities declined from 635 in the 2012 budget year to 485 in 2014. But they rebounded in 2015 to 551, about half of which required medical treatment.
The most dangerous unit was the Potomac Center in Hagerstown, even after a 33 percent decline in assaults since 2012. That facility, which specializes in treating patients with both mental illness and developmental disabilities, reported 180 assaults on staff members in 2015 compared with 85 at Perkins. Spring Grove and Springfield followed with 78 and 66, respectively.
Maryland's psychiatric hospitals have not been immune to the belt-tightening seen throughout state government in recent years.
According to state budget documents, the department's Behavioral Health Administration, which operates most of the hospitals, has 100 fewer full-time employees in its institutions than in 2015, a 3.7 percent decrease. The Developmental Disabilities Administration, which also operates the Potomac Center, is down 10 employees, a 2.1 percent decrease, since 2015.
Meanwhile, according to the report to the legislature, the number of adults admitted to state psychiatric facilities has fluctuated in recent years, rising 10 percent to more than 1,000 in 2014 before dropping about 15 percent the following year to 865. More than 770 of them were considered "forensic" patients.
A work group formed by Mitchell, the health secretary, recommended in August that the state recognize "all state hospitals are forensic in nature." It urged the department to adjust staffing levels, increase salaries and step up training at hospitals other than Perkins.
But none of that has happened yet, employees say.
Starkes said patients at the Springfield therapeutic treatment unit were aware of those deficiencies on Thanksgiving eve. She said she could tell something was brewing about midway through her 3 p.m.-to-11:30 p.m. shift. She said there was an altercation involving patients at a nurse's station about 8:30 p.m.
"I don't know if they were planning something or whatever," she said. "I just think it was an opportunity, and they knew we were understaffed."