On a spring day at Maryland's largest state psychiatric hospital, a patient tried to escape, soiled herself and attacked a caregiver and a hospital police officer. She also spat on the police officer and tried to bite her.
The caregiver had her glasses broken. She was treated at St. Agnes Hospital and missed nine days of work. The police officer missed 12 days of work.
The attacks were part of a spike in assaults on employees at Spring Grove Hospital Center in Catonsville, as the Hogan administration labors under a court order to recruit staff for positions there that were already difficult to fill.
The May 19 assaults at Spring Grove were two of the 68 at the hospital from January through June, according to records obtained by The Baltimore Sun under a Maryland Public Information Act request. That's almost twice the 35 attacks reported in the final half of 2016, and more than any six-month period going back to July 2014.
Psychiatric hospitals are workplaces with known risks of violence. Facilities across the country face persistent problems in attracting qualified people to care for often-dangerous patients.
The Maryland Department of Health is reporting significant improvements in safety at most of its psychiatric facilities. But Spring Grove faces particular challenges.
Patricia Watson, president of the union local that represents most non-nurse employees at Spring Grove, said security has deteriorated in the three years she's worked at the hospital.
"It's getting worse. It's like watching a train wreck," she said. "All you can do is pray and try to help the patients and staff after [an incident] happens."
But John Robison, chief of hospitals at the Maryland Department of Health, called the increase "a blip in patient assault data."
It "does not signal an unsafe place to work," he said.
For many years, the percentage of patients committed voluntarily to Maryland's state psychiatric hospitals has been dropping while the percentage referred by the court system — known as forensic cases — has been increasing. Spring Grove's population is now 80 percent forensic.
The Maryland Health Department, which runs Spring Grove and other state psychiatric hospitals, finds itself in an increasingly untenable bind. It doesn't have enough beds to treat all the people referred by the courts as "not criminally responsible" or "incompetent to stand trial." When the state hospitals legally responsible for treating them can't admit them, sick people languish in jails that are ill-equipped to offer more than stopgap treatment.
Last month, Baltimore Circuit Judge Gale Rasin found acting Health Secretary Dennis R. Schrader and five other top department officials in civil contempt of court — saying the department had willfully dragged its feet in adding capacity.
Rasin, a retired judge who presides over mental health cases in the city, ordered the department to fully staff 20 beds recently added at Clifton T. Perkins Hospital Center in Jessup and staff 20 beds in an admissions unit at Spring Grove. She gave Schrader and his department a Dec. 31 deadline. The state is appealing the decision.
If the order is upheld, state records and interviews with department employees and their union representatives indicate, the state faces a daunting task — even if the Hogan administration comes up with the resources to hire that many employees. Qualified people are not lining up to take such jobs.
April Minniefield, area vice president of the AFT Healthcare Maryland union, said Spring Grove's nursing shortage has worsened and conditions have become more dangerous since she started work there as a registered nurse four years ago. Meanwhile, she said, the state has not made the pay and benefits attractive.
"You have to be competitive with other state facilities," she said. "You have to be competitive with some of the private facilities."
Spring Grove is one step down from Perkins in the danger level of the patients sent there. It houses 343 patients when at full capacity. As of July 25, Rasin found, Spring Grove had 37 patients on its waiting list.
Rasin described Spring Grove in her court order as "a hospital that is being deprived of resources and one that cannot meet its obligations." She noted its chief executive's testimony that the hospital had lost almost 50 positions over the last three state budgets, and spent $5 million last year on staff overtime.
Other state hospitals have had problems with violence and vacancies. The Sun requested records for Spring Grove after hearing complaints from employees there.
The department keeps a monthly log of assaults classified from Level 1 — requiring no treatment — to Level 5, in which the staff member died. There were no deaths in the last three years, but the number of assaults classified as Level 3 — requiring medical intervention — has increased over that time. There were 28 in the first six months of this year, nearly double the 15 in the previous six months.
After inquiries from a reporter, the Health Department produced a chart showing annual assault counts that differed slightly from the totals The Sun compiled from the monthly logs.
The department chart showed 81 assaults in the fiscal year 2015, 78 in 2016 and 98 in 2017. The Sun counted 77 assaults in fiscal 2015, 77 in 2016 and 103 in 2017. Both counts totaled 257 assaults over the three years.
The department did not explain the discrepancies. The Sun is relying on the logs.
Patrick Moran, president of AFSCME Council 3, said all psychiatric hospitals have problems, but Spring Grove's stand out — especially compared with improvements at Perkins in recent years.
Moran said the level of violence at Spring Grove seemed to have leveled off in recent years.
"All of a sudden it skyrocketed," he said.
Moran said the reasons include a more dangerous patient population, too many patients and the staffing shortage. He said Spring Grove, unlike Perkins, was not designed to be a mostly forensic facility, and still is not staffed that way.
Records show that Spring Grove has three positions classified as "building security officers." Perkins, meanwhile, has 80 "security attendants" — the closest counterpart to Spring Grove's attendants, according to union officials.
Watson, who tracks court orders to admit forensic cases, said employees are aware of the increased danger because they're hearing more "codes" — alerts that a disturbance has broken out — and have fewer people to respond. She said she has seen no signs of improvement since June — the last month for which the state provided logs.
The log for June shows there were 13 assaults on staff by patients that month. It was the fourth month since January with at least a dozen assaults. In the previous two years, the most reported in a single month was 11 — a number reached only twice.
Since obtaining the records through fiscal 2017 in September, The Sun has pressed the state to supply the logs for subsequent months. The department declined to do so in time for this article, but reported that there were 24 cases between July 1 and Oct. 6 in which staff members were "struck by patient or third party." If the numbers are comparable, that means assaults have slowed since the first six months of 2017, but still are on a pace to exceed 100 for the calendar year.
The records portray a workplace in which staff members are constantly at risk. On June 5, a licensed practical nurse was punched in the eye while helping to dress a patient and required medical care. The staffer missed four days' work. On June 19, there were three assaults on nurses in a single day.
That morning an LPN had her hair pulled and was punched in the head. That afternoon, two registered nurses were attacked in what appears to have been a single incident. The patient slammed a cart into one nurse's ankle and kicked the other nurse in an ankle as well.
Christopher Garrett, the Health Department's chief spokesman, said patients assault staff at many psychiatric hospitals, public and private.
"Assaults happen," he said. "Patient-related assaults happen at facilities."
Other records show the state has difficulty recruiting for jobs at Spring Grove, where employees do not get the premium "forensic" pay Perkins staff receive. Registered nurses, for instance, can earn $2,000 to $5,000 more per year at Perkins than at Spring Grove.
A listing of Spring Grove's vacancies as of Sept. 18 shows 29 positions at the hospital had been vacant for six months or more. They include five psychiatrist positions and 12 registered nurses. Three posts, all for physicians, had been vacant more than two years.
Robison said the challenge in filling such positions is not unique to Spring Grove. He said the state offers competitive salaries.
"Psychiatrists are extremely difficult to find in every corner of the United States of America," he said.
Robison, who assumed his job a little more than a month ago, said the state devises an individual response to each case of a patient assaulting staff, rather than addressing the attacks as a systemic problem.
"We just don't look at it at an aggregate level," he said.
The hospitals chief, who previously served as chief executive of Perkins, said the security staffing at Spring Grove is sufficient. He noted that Perkins is a maximum-security facility.
"The folks who are admitted to Perkins have a much higher charge level than those committed to Spring Grove," he said.
Robison said there is no proven correlation between staffing levels and assaults.
"I'm confident in saying an increase in patient assaults is not related to staff vacancies or staff morale," he said.
The staff vacancy rate at Spring Grove increased from 6.2 percent in early 2015 to 10.8 percent in June 2016, according to reports distributed to top hospital managers. The department did not report a percentage figure for fiscal 2017, having discontinued distribution of the reports the included that statistic.
Robison said the reports were dropped when the state switched to a new payroll system. He said hospital officials can still call up the data on their computers.
In her contempt finding, Rasin criticized the department for its record keeping.
Accusing the department of "a sort of shell game," the judge wrote that "if the department lacks important data, it has been a conscious and intentional choice not to gather it."
Moran put the blame for Spring Grove's conditions squarely on the Hogan administration. The union leader said the $5 million the state spent on overtime at Spring Grove last year was more than the $4.3 million it spent at Perkins in 2013 to add 93 positions.
He said the state could add 100 positions at Spring Grove for less than it paid in overtime.
"This is all about penny-pinching," he said. "It allows them to say, 'We're not growing government, we're cutting government.'"
Some union recommendations track those of a departmental work group set up last year by then-Health Secretary Van T. Mitchell under pressure from Rasin and other judges.
That group called for increasing staffing to reflect the greater forensic population at Spring Grove, Springfield and other state hospitals. It also called for paying the staff at all state hospitals the same as at Perkins.
Schrader replaced Mitchell last December. Garrett, the Health Department's chief spokesman, said officials have shifted away from the work group's recommendation and are now focused on increasing capacity at Perkins. He said that strategy eliminates the need to upgrade all facilities to the same level of security as at Perkins.