The Lunatics Have Taken Over the Asylum
Staffers at Alameda County's psych hospital have long begged for better protections against violent patients. It took a doctor's murder to get them what they wanted.
February 18, 2004 (eastbayexpress.com)
There must have been an awful commotion, although no one heard a thing. It was a busy county psychiatric hospital, after all, and the Unit C exam room door was closed. But inside, a terrible story was unfolding. During a routine afternoon checkup this past November, Dr. Erlinda Ursua was slain by one of her own patients, a severely mentally ill woman who had been brought to John George Psychiatric Pavilion that morning. The doctor was beaten savagely, according to sheriff's department records, her head and face smashed again and again into a solid object. She also was strangled, according to a not-yet-released autopsy report. Outside the door and just up the hall, nurses, mental health specialists, and doctors went about their work completely unaware of what was happening inside the room. Although the examination room had a panic button, the sixty-year-old MD, who stood only four-foot-eleven, couldn't get to it during the attack.
A hospital janitor made the ghastly discovery later that afternoon. Ricardo Simpson opened the exam room door so he could empty the trash and found the doctor's body on the floor. Her physician's coat was open and her shoes sat next to her feet. An earring, a piece of a jade bracelet, and paperwork were strewn around. No one else was in the room.
Alameda County Sheriff's Department detectives told Lorenzo Ursua that his wife probably didn't die during the beating. She lay there undiscovered for an hour and a half, they estimated, and was most likely alive for at least some of that time.
The suspected killer, 37-year-old Rene Pavon, whose hands were scratched and swollen when she was questioned by detectives later that day, said she became upset when the doctor tried to take her pulse. "I punched her in the neck and her blue wallet and keys went up in the air," she reportedly said. Then, according to a sheriff's department report, Pavon began to ramble unintelligibly.
While staffers at the 88-bed psychiatric hospital were deeply saddened by their colleague's murder, hardly anyone was shocked. For years, they have complained of assaults by patients, many of whom are severely mentally ill and are brought to the San Leandro facility against their will by the cops. Some are homeless; others are transferred from area jails. Many show up after going off their psychiatric medications and arrive in frightening states: They are brought in unkempt and reeking, covered in feces, barking like dogs, or dressed up in costumes. Patients also have been admitted with knives and other weapons stashed in their pockets.
"I've seen so many of my co-workers taken out on stretchers. It's terrible," says Cheryl Omeregie, a mental health specialist at John George who is out on stress leave after saving a colleague's life during a Christmas Day stabbing in 2002.
Stretchers for wounded staff members were all too common in the twelve months prior to Erlinda Ursua's death. One nurse was stabbed twice in the back. Another was punched in the face and had his nose broken. A staff member's head was slammed into a wall so hard she suffered a concussion, and another nearly lost an eye to a pencil-wielding patient. A doctor's jaw was dislocated, and one aide's knee was injured so severely that it required surgery and now has to be replaced. These, according to Dr. Harold Cottman, a hospital psychiatrist, are in addition to numerous less-serious assaults. In 2003 alone, at least six hospital employees went out on workers' compensation leave following patient attacks. But because of poor record-keeping, a top hospital administrator was unable to say just how many other employees went on leave in prior years. Only one thing was certain, the administrator said: "I can tell you there were others."
Despite the repeated attacks and a growing chorus of employee complaints, hospital administrators made few real improvements. By last April, safety had became such a concern at John George that five staffers approached the California division of Occupational Safety and Health, the state's workplace safety agency, to complain.
In June, following an investigation, Cal-OSHA cited the hospital and fined it $30,000 for failing to report two of the attacks as required by law. The state agency also issued a citation for the hospital's failure to maintain an adequate worker safety program. "On a regular basis," one of the citations reads, "employees are suffering injuries from violent patients who assault the employees."
Administrators at the financially strapped county hospital had heard much of it before, and not just from their employees. Cal-OSHA also had cited the hospital back in 1998 for an inadequate workplace safety program. This time around, the agency took the unusual step of making three recommendations that spelled out precisely what they believed needed to be done to protect hospital staff. But rather than implement any of the suggestions, county administrators appealed the citations and fashioned their own set of improvements -- which a number of staff members say were totally inadequate.
"There was no visible change in safety between Cal-OSHA and Dr. Ursua's murder," says nurse Stacey Johnson, who suffered a broken nose when he was attacked by a patient wearing a Spider-Man costume. Neither he nor the other staff members interviewed for this story were surprised by the hospital administrators' feeble response. It was what they'd come to expect. "We'd been complaining about safety for years, and we kept saying eventually somebody was going to get hurt really bad," he says. "They didn't listen. They didn't think there was a problem."
Five months after Cal-OSHA issued its citations, Dr. Erlinda Ursua was dead.
Dr. Ursua was not one of the complainers. The general practitioner loved her job and went about it cheerfully, despite the less-than-cheery workplace environment, her colleagues say. A native of the Philippines, she immigrated to the United States in 1975 with her husband and oldest daughter. Another daughter was born while Ursua pursued her California medical license. She took a job in Alameda County's public health system in 1977 and never left.
Colleagues describe Dr. Ursua as a devoted physician who treated her patients with great respect and patience. She didn't fit the doctor-with-an-ego stereotype; co-workers say she regularly ate her lunch with hospital housekeepers rather than with her medical colleagues. "They used to all share their lunches," recalls Soccoro Smith, a John George nurse for twelve years who has been on workers' compensation leave since 2001. Smith was attacked twice in one month by different patients who hit, kicked, and punched her in the head and neck. "Dr. Ursua comforted me and calmed me down. I was ready to walk off the job," she says.
Dr. Ursua was a stylish woman with a strong maternal streak that extended to both family and patients. Each year she spent a week back in the Philippines, donating her time and medical skills to some of her homeland's poorest and sickest residents.
Lorenzo Ursua, an accountant for the City of San Francisco, is clearly proud of his wife's accomplishments. He arrived for an interview with photos from his wife's most recent medical mission. The pictures show her with her patients: lepers, people with horrible disfiguring tumors, victims of elephantiasis.
Lorenzo says his wife never expressed any fears about her safety, but at work, colleagues say, she often took precautions, such as requesting that a third person be in the room when she conducted an exam. Ursua had not, however, asked a nurse to accompany her into the exam room with Pavon, even though the patient's chart showed she had assaulted a roommate that same morning.
Having a third person present for medical exams was not compulsory -- simply an option if a doctor felt it necessary. A mandatory buddy system, however, was among Cal-OSHA's recommendations the previous June. Although the final decision was left to hospital administrators, the state inspectors strongly urged them to follow through. The agency also encouraged hospital managers to hire trained police officers to patrol the facility and to install a video surveillance system. "Because of the past history of assaults, we took the extraordinary step of making specific recommendations," explains Cal-OSHA spokesman Dean Fryer.
Trustees of the Alameda County Medical Center board of directors, who oversee John George in addition to two other public hospitals and a network of outpatient clinics, were told last summer that the administrators intended to follow OSHA's recommendations, says former trustee Robert Phillips, who resigned last October. "[Chief Operating Officer] Efton Hall assured us that the entire [Cal-OSHA] safety plan would be implemented," he says. "He assured us they'd make significant progress."
Instead, administrators came up with their own plan. "We told administrators to fix it, and they didn't do it," Phillips says. "We were told they were going to make the buddy system compulsory and that they were going to increase security."
Hall, who has since been promoted to interim CEO of the Alameda County Medical Center, strongly denied making such a promise. "Absolutely not," he says. "I never said that."
Several other former and current trustees contacted for the story did not return phone calls. But former Alameda County Medical Center CEO Ken Cohen backs Hall's version. According to Cohen, who attended the board meetings, Hall told trustees that significant safety improvements would be made, but never vowed to implement Cal-OSHA's specific recommendations.
Nor was John George under any obligation to do so, says Mary Ferguson, director of quality and compliance for all of the county's public health facilities. These were suggestions and nothing more. The administrators' improvements, she says, included requesting better-trained security guards from ABC Security Services, which has a countywide security contract. "We changed from two to three guards, changed their qualifications, and we relocated where they would stand," she says. Prior to the Cal-OSHA citations, the hospital used standard-issue security guards. Afterward, it began using better-trained guards, of a caliber similar to those ABC provides for Oakland Airport security.
The hospital, Ferguson says, also made mandatory a once-voluntary policy of screening patients with a metal-detector wand prior to admission. In addition, administrators insisted that the hospital's lobby doors remain closed. This, they hoped, would discourage the assaults that sometimes occurred near the front entrance. According to Ferguson, the hospital had seriously considered a number of security changes and implemented some of them, including the metal-detector wands, even before the state inspectors showed up. "We didn't need Cal-OSHA to come in and tell us to be concerned with safety," she says.
Six staff members interviewed for this story describe a very different administration. They say hospital managers repeatedly failed to make the needed improvements even after the state agency stepped in last year. According to staff accounts, managers seemed to care little about the frightening assaults and told employees the attacks were simply part of the job.
The hospital's own record-keeping, in fact, tells a troubling story of indifference. When asked how many John George employees had gone out on workers' comp leave in the years prior to 2003, Ferguson hit a roadblock. She could definitively say six people had gone on leave last year, but hospital records were so sloppy she was unable to tell how many others there were. "One of the things we've done once this became a big issue is we improved reporting," she says. "We retrained the entire hospital and said we can't correct the problem unless we know what the problems are."
Although the hospital's paper trail is incomplete, the nightmarish attacks are unforgettable for many employees. In their interviews with a Cal-OSHA inspector last summer, the five staff members described an environment in which being hit, kicked, punched, and bitten by patients was routine. Also commonplace, they said, were inattentive, uninterested administrators.
Debra Mapp, a nineteen-year mental health specialist at John George, recalled an attack two to three years ago in which a mentally ill man coming off cocaine was masturbating in the lobby. She asked him to stop and he became angry. A while later, in one of the hospital's hallways, he threw her into the wall, knocking her unconscious. "I got no assistance from anybody," Mapp told the Cal-OSHA inspector. "I had to drive myself to the emergency room."
Mapp also recounted a disturbing incident from just a week before her conversation with the inspector. When a patient on one of her shifts became agitated and threatening, Mapp said she got frightened and pushed a panic button to summon help. "You are supposed to drop what you are doing and come when that panic button is pushed," she told the inspector. "Nobody came."
Nurse Vicki Filomeo, who has worked at the hospital for ten years, was asked by the inspector what assaults she could remember from the previous six months. She rattled off a disturbing list: "Ruby got a concussion three months ago. Dr. Zeller got hit in the face and dislocated his jaw. I was hit with a garbage can." The three other employees interviewed had similar stories.
Several employees, including Johnson, pointed to the inadequacy of the unarmed security at the unit. The guards, they claimed, did little if anything to protect staff from out-of-control patients. "They're fearful and they're afraid of getting hurt themselves," Johnson told the inspector.
Employees viewed ABC Security's guards as all but useless, according to numerous staffers. Some reportedly stole from nurses and doctors, psychiatrist Cottman says, while others didn't speak English. And hospital employees told Cal-OSHA that nearly all of their would-be protectors feared the patients. ABC Security Services did not return phone calls for this story.
In an interview with the Express, mental health specialist Cheryl Omeregie recalled the Christmas 2002 attack in which a patient stabbed a nurse in the hospital lobby while an ABC guard stood by. Omeregie herself had to knock the knife out of the patient's hand. The nurse had already been stabbed twice and probably would have been killed had Omeregie not stepped in, her colleagues say. When she asked the guard why he didn't intervene, he reportedly replied, "They don't pay me enough to get involved."
The guards were allegedly so ill-equipped for the circumstances that John George psychiatrist Harold Cottman wrote to hospital administrator Sandra Holliday last July and pleaded for armed, trained peace officers to patrol the two-building complex. "Let me assure you," he wrote. "Even the most psychotic patient understands the difference between a law enforcement officer with police power and a security guard, some of whom have criminal records."
Neither Cal-OSHA's recommendations nor Dr. Cottman's prodding convinced the administrators. The county health system faces a $25 million deficit this year, and bringing in sheriff's deputies would have cost additional tens of thousands of dollars annually. Ferguson says administrators considered doing it back in 2002 but gave up after the sheriff's department insisted that two officers, not one, be assigned to the hospital. The medical center couldn't afford the cost and the sheriff's department wouldn't budge. Two deputies were needed, sheriff's officials insisted, because the assignment was far too dangerous for a single officer.
John George is hardly the only psychiatric hospital that has to contend with combative patients. In fact, the statistics are staggering. The federal Occupational Safety and Health Administration reported last year that mental health workers were five times more likely to be the victims of nonfatal violent crime on the job than workers in any other occupation. In a 1998 report, Cal-OSHA warned that psychiatric workers "may be at a higher risk for injuries from assaults than the risk for injuries from all causes in the country's most hazardous industry."
The epidemic of assaults can be blamed in part on dwindling funding for outpatient mental health services. Outpatient clinics helped the severely mentally ill stay on their medications and acted as a kind of safety net. But as money dried up and clinics were shuttered, emergency admissions at psychiatric hospitals across the country increased dramatically. "About 50 percent of our patients are dually diagnosed," says Dr. Cottman. "They are bipolar or have schizophrenia along with drug and alcohol problems. Drugs are getting cheaper on the streets, and the ability of those drugs to alter the mental status of our patients has increased at the same time budgets of mental health services have been cut."
There's another reason for the increase in assaults, experts say, and that is the extent of civil rights protections afforded the severely mentally ill.
Once housed in psychiatric institutions that have all but disappeared over the last three decades, these patients were often the victims of psychiatric abuses. They were forcibly drugged, secluded, and restrained -- sometimes for days at a time. Some received lobotomies and electroshock therapy against their will. As a result, nearly every state has since enacted laws that greatly restrict how mental health workers can manage their out-of-control patients.
In California and many other states, a hospital may not forcibly medicate a patient or use restraints, unless there is an imminent threat to the patient or others. "Many people at the state level say a patient has to assault someone for it to qualify as an emergency," Mary Ferguson says. "They have to actually hit somebody."
California's Lanterman-Petris-Short Act mandated tough civil rights protections for the mentally ill back in the late '60s, and other states soon followed suit. Although the law has been on the books for three decades, the restrictions became increasingly problematic as patients were released from institutions and outpatient services disappeared.
"We are trying to undo all the damage these civil rights groups have done," says E. Fuller Torrey, a psychiatrist and board president of the Treatment Advocacy Center, a Virginia-based nonprofit that aims to eliminate barriers to the timely treatment of severe mental illness. "The civil rights advocates and antipsychiatry groups, including the Scientologists, have made it extremely difficult to properly medicate or, when necessary, seclude highly disturbed patients in the hospital," he says.
Unfortunately, Torrey adds, "The people who have encouraged these changes usually have no experience themselves with people who are severely psychiatrically ill."
California still has some of the nation's strictest laws relating to treatment of the mentally ill. Helen Thomson, a former Davis assemblywoman who is now a Yolo County supervisor, sponsored legislation in the late '90s that would allow psychotic patients to be medicated through court-mandated outpatient services. But although former Governor Gray Davis finally signed it in 2002, no funding was attached, making the new law basically meaningless. "It's better for these people to be mandated to take their medication in an outpatient setting," Thomson says. "In New York, they've changed the laws and it's been very successful. A judge orders them to take their medication and they do."
There are additional civil rights protections that make working on a psych ward even tougher, according to John George administrator Ferguson. In particular, strict federal rules regarding the use of restraining devices have created enormous challenges for the county hospital. "Many of the [assault] problems we see began to happen in 2002 when the feds asked this hospital and every other hospital in the country to submit a plan to reduce restraints," Ferguson explains. "We saw a lot of problems around the organizational effort to decrease restraints."
With the few options mental health workers now face, Supervisor Thomson says it's all the more imperative that hospitals provide "lots of security and additional staffing" to protect employees from out-of-control patients.
San Francisco General Hospital's psychiatric ward, a publicly funded facility with a population comparable to that of John George, faced similar problems with patient assaults a few years back, but administrators there responded appropriately, says Gary Robinson, executive director of the Union of American Physicians and Dentists, which represents one hundred doctors employed by Alameda County. "SF General has not had the same kind of problems since," he says.
From interviews with staffers at SF General, it's clear the issue has long been a priority for hospital management. "We are quite vigilant with regard to violence in the workplace," says Sharon McCole Wicher, director of the hospital's behavioral health department. "We have an assault-and-battery review board comprised of managers and direct caregivers and we review all cases of assault on a regular basis and, as a result of this review, we make changes."
Everyone on the San Francisco unit, including the janitors, carries personal alarms that sound loudly when they are activated. Patients are searched before they are admitted, and sheriff's deputies patrol the entire hospital complex. Doctors are not allowed to conduct one-on-one exams with patients, and staff members are regularly trained in crisis management. "The risk is always there, but our goal has to be to prevent assaults," says Dr. Mark Leary, the hospital's deputy chief of psychiatry.
A very different attitude prevailed at John George, according to union leader Robinson. "Alameda County and the medical center has had no interest in safety," he says bluntly. "The administrators just didn't want to hear it, and their plates were full."
Cal-OSHA is once again investigating the John George psychiatric hospital. This time, the inspectors aim to determine whether management had knowledge of safety and health violations that contributed to Dr. Ursua's death, but made no real attempt to correct them. "The question is whether any safety measures they implemented were sufficient enough to prevent violations that would lead to serious injury or death of any employee," Cal-OSHA's Fryer explains.
If the state agency concludes that administrators intentionally disregarded the hazards, it could issue a willful violation, which carries a $70,000 fine. Even then, John George's troubles are far from over. Two weeks ago, the federal Centers for Medicare and Medicaid Services did a surprise inspection, and found the hospital to be inadequate in four of the seven areas examined.
Although the details have not yet been made public, the federal inspectors typically look at staffing, patients' rights issues, and hospital governance. The feds gave John George officials ten days to submit a correction plan -- failure to fix the inadequacies could cost the hospital federal funding and accreditation.
Rene Pavon remains in custody of the county. She has been charged with murder by the Alameda County District Attorney's Office, to which she entered a plea of not guilty in late January.
Meanwhile, former trustee Robert Phillips hopes the bureaucrats in charge of staff safety will pay for their indifference. "I believe people directly responsible for failing to implement safety measures, which the board was promised were being implemented, should be fired," he says. "[Ursua's] murder was totally unnecessary."
Dr. Lene Martinez, an obstetrician and Ursua family friend, says the pain of Erlinda's death is only now beginning to sink in for Lorenzo. For several weeks afterward, he was surrounded by family and friends nearly every night, but lately the visitors have come by less frequently.
Lorenzo Ursua seems like a man who has willed himself to stay numb. He doesn't cry; he doesn't grandstand; he just answers questions and steers clear of emotions during a recent interview. As for the hospital administrators, he says only, "They didn't do their job, and I don't know how they should answer for that."
Mary Ferguson says that while she is deeply troubled by Dr. Ursua's murder, blame cannot be easily assigned. "You have to look at the whole environment. This didn't happen because someone didn't do their job," she says.
Things have changed at John George since November. Sheriff's deputies now patrol the hospital. Every staff member carries a personal alarm. And doctors may conduct exams only with a third person present in the room. It has all shaped up just the way nurse Stacey Johnson predicted: The employees would get everything they wanted once somebody got hurt really bad.'
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