Fear Is Making the Rounds at Atascadero State Hospital

By the time most colleagues heard the emergency alert, Wahida Abdeen-Poncelot was unconscious, her blood pooling beneath her. Her head was gashed, a kneecap shattered.

The diminutive psychiatric technician had just worked a double shift at Atascadero State Hospital, a mental institution for patients funneled through the criminal justice system.

As she headed for the door of her unit that November night, a patient slammed her against a wall. After a co-worker grabbed the attacker, a second patient jumped Abdeen-Poncelot. She might have died had a third patient not intervened.

Raymond Albert Lopez, 34, later told hospital police that his alleged accomplice, 29-year-old Lynford Jay Perry, gave him “uppers” in a bathroom as they planned the attack. “He hit her and I finished her off,” said Lopez, who with Perry is facing charges of attempted murder and conspiracy.

Brutal, premeditated attacks are rare, but this one sent tremors through the ranks at Atascadero, which has seen a 66% jump in hitting, kicking and other aggressive acts against staff in the last two years. There were 374 such assaults between July 2004 and June of last year, up from 225 two years prior.

The jump is not the worst in the state’s five-hospital system; such incidents at Metropolitan State Hospital in Norwalk more than doubled. But psychiatrists, nurses and others at Atascadero say they face particular peril because the facility is taking on increasingly combative patients in already-crowded wards just as it contends with an unparalleled staffing shortage.

As it stands, the Central Coast facility houses the state’s largest share of mental patients likely to be violent -- including criminal defendants acquitted by reason of insanity, mentally ill parolees and those who have completed parole but pose too much of a threat to be released.

Staffers fear that the danger grows with every shift.

“In 16 years here I’ve never felt unsafe,” said Dr. William Walters, a psychiatrist and vice chief of the medical staff that covers 75 severely ill parolees in two units -- Abdeen-Poncelot’s among them. “I now feel I’m just waiting to get hit.”

The trend is a jarring setback for a facility that took a national lead more than 15 years ago in calling attention to violence as an occupational hazard. Through its Clinical Safety Project, the hospital dramatically reduced serious staff injuries, trained employees to manage aggressive patients and enlisted patients in counseling peers. But a recent analysis by Atascadero officials shows that the rate of assaults against staff members by patients considered the most volatile -- on parole or confined beyond their parole terms -- has tripled since January 2003.

Atascadero houses the largest proportion of such patients, called “mentally disordered offenders,” and their numbers are growing. Staffers say a key factor in the upheaval at the hospital is court rulings in 2004 that granted the patients the right to refuse psychotropic medications.

Clinical Safety Project director Colleen Love stressed that the hospital has been successful over time in reducing serious injuries that curtail work duties or require more than first aid, but those recently have climbed as well -- from 69 in 2003 to 76 in 2004 and 81 last year.

The increased violence and injuries come as the state’s mental hospitals face intensive scrutiny by the U.S. Department of Justice. That agency, however, has previously focused mainly on violations of patients’ rights, including possible overmedication and excessive use of restraints, not staff security.

Indeed, federal investigators issued reports on Metropolitan and Napa State hospitals that were highly critical of staff members’ failure to prevent patients from harming themselves or other patients. The agency only recently completed reviews of Atascadero and San Bernardino’s Patton State Hospital -- which is reeling from two recent killings of patients by their peers.

Now Atascadero, like other hospitals in the system, is poised to shift to a new model of care that is less restrictive for patients, offering them more autonomy, interaction with peers and individualized treatment. Though many staff members support the concept of this “recovery model” -- pioneered at Metropolitan -- they fear that it requires far more manpower to be carried out safely.

As it stands, more than a quarter of Atascadero’s budgeted positions for nurses, psychiatric technicians, psychiatrists and other caregivers were vacant last January -- compared with a 12% vacancy rate at Patton and 2% at Metropolitan and Napa, according to the most recent state data.

The shortages at Atascadero, which houses more than 1,300 patients and has more than 2,200 budgeted staff positions, are worse still when staff members who are on leave -- many due to assaults or stress -- are included. In one program that includes the hospital’s high-stress admissions units and its medical unit, 10% were on extended leave as of Dec. 1.

In a report issued after a survey of Atascadero last month, inspectors with the hospital accrediting agency, the Joint Commission on Accreditation of Healthcare Organizations, noted that a quarter of full-time nursing slots and a third of psychiatrist positions were vacant. They said failure to promptly reverse the trend would result in “diminishing safety for patients and staff.”

Psychiatrists and nurses note that many colleagues have left recently for a new state hospital in Coalinga and the nearby California Men’s Colony, which they consider safer -- though less therapeutic -- because of the presence of armed guards. The departure of colleagues only worsens conditions for employees who stay.

“It’s sort of a downward spiral,” acknowledged Atascadero Executive Director Mel Hunter, who has pressed Sacramento officials to offer better pay and incentives.

Stephen Mayberg, director of the state Department of Mental Health, called staffing constraints systemwide “legitimate and really problematic for us.... Vacancies are difficult, and running all our hospitals at or above capacity all the time just gives us no breathing room.”

Unable to keep pace with a growing, more challenging patient population, the state has turned to overtime. After two more housing units opened in November 2004, mandatory back-to-back shifts became common. In June 2005, nurses and psychiatric technicians worked 25,733 hours of overtime -- a 67% increase since June 2003.

Atascadero also is relying increasingly on less-experienced staff -- including students as young as 18. The night Abdeen-Poncelot was assaulted, the first staffer to respond from her own unit was a student who ran to call 911 instead of helping to restrain the attackers, hospital police reports show. (Police had already been summoned through pager devices that all staffers carry.)

Even experienced staff increasingly fill in on units where they have no established relationships with patients. “I hear it all the time,” said Dr. John Cannell, a psychiatrist and union steward: “I don’t know the patient. I’m a float.”

Moreover, the number of more typically aggressive mentally ill offenders -- many of them emergency transfers from overcrowded prisons -- has grown, administrators said.

The toughest arrive directly from prison seclusion, and often find themselves free to roam through units or cavernous hallways and courtyards. By law, they are subject to restraint only if deemed a threat to themselves or others.

One patient in an admissions unit last month gouged his hand with a staple torn from a magazine while yelling, “I’m from Pelican Bay.... I’ll take you all out!” an incident log shows. He then tackled staffers.

Aggressive behavior has increased with recent court decisions that allow patients -- including the mentally disordered offenders -- to refuse medications, many staff members said.

“Not only did they start refusing their psychiatric meds, they started refusing their diabetes meds and their lab work,” Walters said.

Medication can be forced on patients deemed by doctors to pose an “imminent danger” to themselves or others. But those who receive such emergency medication are entitled to an on-site hearing with two psychiatrists, a psychologist and a social worker, and follow-up hearings at the 14-day and 180-day mark.

It’s a time-consuming, labor-intensive process. Atascadero has held more than 320 in-house proceedings for mentally disordered offenders since December 2004 -- far more than any other state hospital.

The more experienced workers rely on their powers of persuasion. When parolees refuse medication, seven-year psychiatric technician Hollie Thomspon approaches them an hour or so later to quietly coax. “I tell them, ‘Hey, medication is part of treatment,’ ” she said.

In general, however, staff members say patients’ refusal of drugs has led to increased aggression in the wards. Joan Trabucco, a psychiatric technician, said every female worker in her admissions unit had been hit within the last three months.

In one unit, staffers who had worked the morning shift recently described patients’ moods to their evening replacements. One had been refusing meds for about a month. “I think he’s really cracking,” a psychiatric technician observed. “He is,” the daytime shift leader replied, “and when he goes off, it’s really going to be something else.”

Love said patient overcrowding is partly to blame. In 2005, the hospital began doubling up parolees in single rooms and housing them in former office space. Close quarters might have caused assaults against fellow patients and staff members to spike, Love said.

She said the problem is all the harder to contain because staffers are exhausted from overtime shifts.

Some relief came when officials began moving sexually violent predators -- who generally are not assaultive -- to the state’s newest mental hospital in Coalinga three months ago. However, more typically aggressive patients have replaced them.

Administrators and staff stress that most patients are docile. But the growing number of repeat aggressors has created a profound sense of fear in the wards.

Toni Martin, a 19-year veteran, was struck repeatedly in August by a patient who had intermittently refused medication. “He just said, ‘You’re in with them’ and started pounding me,” she recalled.

Martin, named “Nurse of the Year” before her assault, returned from a two-month leave nervous and wary. As staff members responded to a violent episode weeks later, she said, she huddled at the nurses’ station and cried. “It always comes back to you,” she said, “every time a friend gets slammed or hurt.”

Many caregivers are suffering from high blood pressure, depression and ulcers, they said. In growing numbers, they are submitting notes from their doctors ordering them to forgo overtime.

Pamela Garofalo, a 25-year employee, reached her limit last summer when a colleague with mounting blood pressure had a stroke. She began distributing a series of fliers and e-mails encouraging employees to refuse certain voluntary overtime shifts. Psychiatrists also are speaking out, warning Mayberg, Atty. Gen. Bill Lockyer and other state officials that further tragedy is guaranteed if staffing shortages continue. We “can no longer live with the violence at our hospital,” Cannell wrote in a Dec. 29 letter to the governor and two local legislators.

Meanwhile, Abdeen-Poncelot, who declined to be interviewed, is trying to heal. Her husband, a nurse at Atascadero, said she is scared and withdrawn, and cries when she passes the hospital’s freeway exit.

Hunter declined to comment on the attack, citing the ongoing prosecution. But he said “being assaulted is not a work requirement

“There’s a lot of anger,” said David Powell, a nurse who works in the hospital’s urgent-care unit, recalling the night Abdeen-Poncelot was carried in on a backboard, blood matting her black hair. “It could have been avoided.”