WALKING THROUGH THE noisy wards of Western State Hospital last October, among aimlessly milling mental patients, federal investigators must have wondered who was crazier—the inmates or their keepers. The three inspectors from the US Department of Health and Human Services stopped to chat with a harried hospital staffer who told them he was assigned up to 80 patients in three wards and was often unable to attend treatment-team meetings. But over in Ward C8, on another floor of the hulking red brick hospital in Steilacoom, staffers were twiddling their thumbs. "There is [no therapy programming] on after 5pm," one nursing staffer said. "We bring in movies from home, or popcorn—anything to break up boredom."
The HHS inspectors concluded that, after 127 years of trying, Western State Hospital still wasn't getting it right. Their surprise compliance review—required of hospital facilities receiving federal funding—found Western's mental-health-care treatment plans inadequate. Records were incomplete, proper staffing and care were lacking, and some wards had a badly mixed stew of patients with different illnesses requiring different treatments.
The litany of failings sounded drearily familiar. Reviewing patient records, the inspectors found one developmentally disabled patient who had been either locked in a room or held in restraining devices for 512 hours during the month of August—almost 70 percent of the time. Yet what were the alternatives for patients when they weren't locked up? A sampling of 20 patient records showed that treatment plans were sorely lacking or consisted of such vague generalities as "Decrease suspiciousness and isolation." Each record failed to meet established standards for assigning patient needs, strengths, goals, and treatment.
The investigators also found that therapy sessions had become electives—Western patients could choose not to attend. They could instead stay in their rooms, wander the wards, or meander out on the hospital grounds. But then, it's not as if therapy sessions were abounding at Western: A check on one 28-patient ward—where seclusion and restraint use were found excessive—determined that in the next five days only two patients had sessions scheduled.
Other patients, meanwhile, seemed to be lost in the system. A mentally disturbed woman admitted on September 9 had no treatment plan drawn up until September 17. When an inspector talked to her on October 12, she still had no group therapy sessions set. But again, what kind of therapy could she expect? At one session, says an inspector, hospital staffers "were struggling to maintain group cohesion when the ward staff announced 'Snack Time' for patients over the PA system." Once patients returned from snacking, the PA then announced that a "community meeting is starting and all patients are to come to the community area," breaking up the session once again.
The inspectors summed it all up in a report released this month: At Western, "[s]eclusion and restraint is used extensively with no clear plan of action to reduce its use with individual patients," and "[m]any extended-care units provide little activity for patients, leaving only medication as the major intervention."
IN SHORT, WESTERN was warehousing patients again. There's a history of it at the venerable psychiatric hospital, home to approximately 1,000 of the state's mentally ill citizens. And once again, if the state doesn't correct its deficiencies to comply with federal regulations, it could lose up to $50 million in Medicaid and Medicare funds. That in effect would shut down the state's major mental facility.
Defunding threats are leveled first to get a hospital's attention, and this one seems to have worked: The state is scrambling and promising to have a corrective plan in place by the end of the month, averting the threatened February cutoff. "We're fixing things," says Lyle Quasim, Department of Social and Health Services secretary, promising to review policies and hire more qualified staffers. DSHS blames it all on a sudden rise in patient population due mainly to changes in commitment laws—in particular, those affecting mentally ill offenders.
It's a dilemma the state says it didn't see coming and can solve with more money. But why do Western's shortcomings redux come while there has been a multimillion-dollar state budget surplus? And why do some think these same problems will continue long after the extra billions—in tobacco settlement money, for example—begin to flow cofferward? History, perhaps?
In addition to their illnesses, Western's patients have long suffered from chronic official neglect—followed by a flurry of chronic official corrective action when the cork pops. It usually takes another frightening escape or tragic killing—and the predictable public uproar—for everyone to spring to action.
The recent US survey is a warning that the pattern continues. The US probers found that Western's defects were evident months back when, in one case, six developmentally disabled patients were being isolated or restrained for inordinate periods. During one month, the half-dozen were held in "tack"—leather restraints—an aggregate of 1,787 hours. Their treatment charts, conversely, lacked any plans for intervention. Because records were poorly kept, US inspectors also could not determine whether patients were being released once their behavior had stabilized, leading them to believe that some were being held longer than necessary—possibly as punishment. Whatever the cause, inspectors found the isolation/restraint use "excessive."
CONTINUED OVERMEDICATION AND overuse of restraints seems not to trouble a public indifferent to such problems but indignant about their effects. Yet such practices have proven tragic, as in the 1994 case of 74-year-old Gordon Enbusk. The combative Alzheimer's victim was checked into the hospital by his family in August. In September, he was discharged to go home and die. He arrived on Steilacoom's doorstep mostly unmarked and in reasonably good health; he departed five weeks later covered with bruises, suffering from malnutrition and dehydration, unable to speak, with an untreated gaping wound and bearing signs of having been raped. He was dead within days of his release. (See: "Last days," SW, 9/18/96.)
Enbusk's family claimed he was essentially harnessed in restraints and forgotten. The state investigated and declared itself not guilty. Enbusk, who survived the D-Day invasion of Normandy and won a medal for bravery, couldn't survive Western's care. And in a chilling and revealing postmortem, the state concluded that hospital staff had treated Enbusk "the best possible way they could."
Officials claimed they had closed the books on the Enbusk case. But we've now learned the state paid the family $95,000 in an out-of-court settlement. That was after a Pierce County Superior Court judge last fall decreed the old man was indeed badly injured by overuse of restraints, and said there remained serious questions whether the state "did adequately protect Mr. Enbusk from harm."
The recent US survey suggests that others may similarly lack protection. As Enbusk's attorney Randall Brown told us back in 1996: "Sadly, I do not think Mr. Enbusk's experiences at Western were all that unusual." He hoped—futilely, it appears—that the state would not prove him a prophet.