Alameda County hospital labeled a 'trouble spot'
Psychiatric ward had raised red flags before fatal attack
Rick DelVecchio, Chronicle Staff Writer, SFGate.com
Friday, November 28, 2003

Violence broke out more than 100 times last year and earlier this year at Alameda County's public psychiatric hospital, and two state agencies soon came knocking with questions about how the beleaguered center deals with unruly patients, a Chronicle review of records shows.

The county-run John George Psychiatric Pavilion in San Leandro is under scrutiny again after the slaying of the hospital's lead internal medicine doctor in a private exam room on Nov. 20. A 48-year-old patient, Rene Pavon, has been charged with fatally assaulting Dr. Erlinda Ursua, 60.

Last week's incident was the most severe since hospital officials earlier this year began documenting violence by patients on other patients and on staff, prodded in part by the state Department of Health Services, Cal OSHA and unions representing hospital workers.

The troubles at John George come as the Alameda County Medical Center, which runs the psychiatric center, Highland Hospital and other health care services for indigent and uninsured residents, is in the midst of a fiscal and management crisis.

Faced with an $80 million deficit, the medical center has been forced to close clinics and deal with the resignations of its top brass and nearly half its board of trustees. County supervisors voted this week to ask voters to raise the county sales tax in an attempt to stop more services from being cut.

A 'trouble spot'

"John George is going to need a major overhaul," said Supervisor Gail Steele, who called the hospital a "trouble spot" in the public health system. "You can't have staff endangered."

The psychiatric hospital reported 15 assaults from Dec. 24 to April, and 94 "violent gestures" throughout 2002, health services department logs show. Those incidents included assaults on other patients or workers where staff members had to intervene. Some resulted in injuries, but state records do not say how many.

The hospital has 80 beds and handles 3,000 patients a year, many of whom struggle with schizophrenia, bipolar disorder and depression. Some, like Pavon,

are brought in by police to be evaluated for 72 hours because they appear to be a danger to themselves and to others. The day before Ursua was killed, Pavon went to John George by ambulance after her family in San Leandro called police for help.

The notes of state hospital licensing inspectors provide a glimpse into the stresses and complexities of life inside a psychiatric institution.

A pajama drawstring poses a suicide hazard. A patient complains of feeling like a dog for having to sleep on a mattress on the floor. A man locked up for threatening to chop up his mother throws chairs at another patient in the lounge. A transgender patient is upset over bathroom accommodations. A psychotic patient threatens to kill hospital workers. The kitchen's roast beef isn't chilled enough. A staffer, who is later fired, punches a patient in the face after they have words over the patient's nicotine gum prescription.

When state inspectors asked a nurse manager about the therapeutic goals and education for an assaultive patient who had caused three injuries despite having been medicated 14 times in 16 days, she answered simply, "We try."

John George has retained its state license as the Health Services Department continues its investigations. The problems seen so far are not out of line with other psychiatric facilities, department spokesman Robert Miller said.

A new low?

Still, some employees wonder whether the death of a worker and injuries to others mean that the hospital's organizational crisis has hit a new low.

"I don't think you'll ever get to a situation where there are zero patient assaults on staff, but that's what you need to work toward," said Brad Cleveland, spokesman for Service Employees International Union Local 616. "There hasn't been the leadership at John George to put the changes in place to prevent the kind of tragedy that happened the other day.

"I don't think there's been any progress," he said. "Heads need to roll."

The center faces its huge deficit despite having closed two clinics and cut other services, prompting county supervisors to appeal to the voters to pass a half-cent sales tax increase to halt the financial slide. The measure would go on the March 2 ballot if the supervisors, as expected, give it their final approval next week.

At the same time, county supervisors and the center's board of trustees are struggling to recruit a permanent medical director to replace Kenneth Cohen, who left in September, and new trustees to succeed the five who resigned at the same time.

Four of the five departing board members said they were fed up with the divisiveness between the center's 11-member board and county officials over how to run public health services. The county set up the center as independent in 1998 but hasn't given it the resources it needs to stand on its own, they said.

On Monday, the center's chief nurse executive, Ellen Waxenberg, also resigned, citing the center's inability to keep track of the nursing work force, its slowness to recruit nurses to fill vacancies and a hostile work environment caused by open union grievances "too numerous to count."

She also questioned the center's leadership in the wake of Cohen's departure.

"The cohesiveness is vanishing, and the institution is slipping back to its old way of doing work," she wrote in her resignation letter.

Workers at risk

Last week's fatal encounter occurred when Ursua and her patient were alone. Hospital officials say they did not assign another employee to the room because Pavon's record did not indicate she was an assault risk. They have since changed that policy, at least temporarily.

Hospital workers are four times more at risk of getting hurt on the job than workers in all private industry, and psychiatric wards are among the areas where violence is most frequent, the federal Centers for Disease Control and Prevention said in a report last year.

Working alone and lack of staff training on how to handle potentially violent patients are among the risk factors, the report said.

In response to numerous complaints, Cal OSHA cited John George in 1998 and again in June for not having a proper injury-prevention program. The agency also fined the hospital for failing to report two violent assaults on nurses.

In August 2002 and again in April, the health services agency found fault with the hospital's handling of four patients who had committed violent acts.

In late 2002, hospital officials began monitoring patients more closely to reduce or prevent violence. By April, they formed a committee to improve service and made it answerable to top management. And they gave unit managers the job of logging and reviewing all reports of patient assaults.

John George officials have declined to discuss specific cases and the status of their efforts to reduce violence, citing patient privacy.

Robert Blackburn, a former medical center board member, said worker safety had always been a high priority for management. "I don't know what anybody could have done differently," he said, referring to the fatal assault.

However, Blackburn also pointed to the center's fiscal problems.

Last week's fatality was "a wake-up call that there is a certain budget line below which you cannot go," he said. "It's a tragic reminder."

E-mail Rick DelVecchio at rdelvecchio@sfchronicle.com.