St. Elizabeths mental hospital still falls short, report says

By Henri E. Cauvin
Washington Post Staff Writer
Wednesday, December 30, 2009

The U.S. Justice Department says that despite progress on some fronts, St. Elizabeths, the District's hospital for the mentally ill, is falling short in patient safety, nursing care and other areas covered by a court settlement intended to reform the infamous institution in Southeast Washington.

In a new report, civil rights attorneys for the federal government fault the hospital's handling of violent incidents and say that a gang rape of a female patient last summer highlighted some of the very safety problems that the Justice Department has been urging St. Elizabeths to correct.

The report, completed this month, notes improvement in some areas, and the District says the assessment reflects "substantial progress." But the 10-page letter that prefaces the 369-page report makes clear that the attorneys believe St. Elizabeths is still not in compliance with the settlement.

Indeed, the findings reflect the steep challenges facing the District as it attempts to remake the hospital and the rest of the mental health system and to end the long-running class action suit over care of the mentally ill. From the new hospital building that is scheduled to open in March on the St. Elizabeths campus to the closure of the government's main outpatient treatment agency, the D.C. Department of Mental Health has hardly been still over the past few years.

But the pace of change has yet to satisfy the federal judge overseeing the class action suit or the Justice Department team monitoring the settlement agreement for St. Elizabeths, the only public psychiatric hospital in the city and a landmark with a long, sometimes troubled history.

After a run of deadly violence among patients several years ago, the Justice Department's Civil Rights Division launched an intensive investigation into conditions and care at the hospital. A settlement agreement negotiated with Justice in 2007 mandated major improvements at the hospital and regular reviews by federal monitors.

More than two years into the agreement, the hospital has yet to fully comply with most of the more than 200 requirements, though the District says it has partially or substantially complied with 83 percent. Only 23, including six that are not due until June, are classified as noncompliant, down from 40 in March. "This reflects real progress and a strong commitment to improving care," D.C. Attorney General Peter Nickles said in an e-mail.

While the numbers reflect improvement, the areas of concern are significant -- and persistent. After a visit to St. Elizabeths earlier this year, the monitors gave the hospital "unambiguous notice" about critical issues that had to be resolved by their next visit. But when they returned in September, many were still unaddressed, the chief of the Justice Department's special litigation unit, Shanetta Y. Cutlar, wrote in the letter to the District.

In examining the hospital's efforts to protect patients, the department found that St. Elizabeths was not in compliance. The staff, for example, was not tracking repeat victims and repeat aggressors nor was it properly following up on high-risk behavior and ensuring that it was addressed during treatment planning.

The alleged rape of a female patient by four other patients in July underscored some of the shortcomings in patient safety, Cutlar said. The incident was not even mentioned during routine treatment reviews of three of the four alleged attackers. But while the documents failed to note the rape allegation, one of the alleged assailant's documents recommended, without explanation, that the patient be observed for "sexually inappropriate behavior."

A tracking system has since been put in place, a hospital spokeswoman said yesterday.

The examination of nursing practices at St. Elizabeths found the hospital to be out of compliance in that area as well. While praising the efforts of the new chief nurse, the Justice Department said that St. Elizabeths was not doing enough to address "substantive deficiencies" in nursing and that progress was so slow that the hospital was unlikely to meet the deadlines for "substantial compliance" with the requirements.

Every unit, for example, is supposed to have a registered nurse on duty at all times, but monitors found that the hospital continues to fall short. The "lack of RN coverage," the monitors say, "puts patient health and safety in jeopardy."

A registered nurse is now on each unit 97 percent of the time, up from 87 percent during the Justice Department visit, the hospital spokeswoman said.

The most encouraging progress, a patient advocate said, has been in the attitude of some of the hospital's top managers. That is starting to change the way the hospital actually works, said Mary Nell Clark of University Legal Services, which represents patients at St. Elizabeths. "There's a long, long way to go," she said. "But there are definitely more people there that seem to have a desire to make the place better."

Psychiatrist Richard Ratner, who has been a consultant at St. Elizabeths, said that the hospital's chief executive, Patrick J. Canavan, has been instrumental in bringing in people who are invested in the future of the hospital. "They really are in there to do the job, to make the place better."

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