A patient accused of killing a 29-year-old nurse on the grounds of the Hawaii State Hospital had been in and out of the institution since he was a teenager and had a history of drug abuse, an employee said.

Staff at the Hawaii State Hospital have been badly shaken by the stabbing death on Monday evening in a case that is prompting new questions about safety at the state-run facility for the mentally ill.

A team of inspectors from three agencies including Hawaii Occupational Safety and Health is about the descend on the state hospital, according to the employee, who provided new details on condition of anonymity.

Tommy Kekoa Carvalho, 25, was arrested on suspicion of second-degree murder in the slaying of licensed practical nurse Justin Bautista. State hospital Administrator Kenneth Luke described Bautista as a “well respected and well loved” employee who had worked at the facility for four years.

Carvalho had been confined in the hospital for about a year before transferring in August to an outpatient program that operates from four cottages on the hospital grounds, the staffer said. Those cottages are outside the secure, newly built $160 million Hawaii State Hospital complex.

Monday’s attack occurred in the medication room of the transitional facility, the employee said.

The Honolulu Emergency Medical Services responded to the hospital in Kaneohe at around 5:15 p.m. Monday and found the nurse with multiple stab wounds, according to EMS spokeswoman Shayne Enright. Bautista was pronounced dead at the scene.

The suspect suffered a minor injury to his finger and was transported to an emergency room at another facility in the area.

Hospital officials and police declined to say what type of weapon Carvalho allegedly used or how he acquired it, but the hospital staffer described the weapon as a pocket knife.

Carvalho had been ordered to the Hawaii State Hospital four times, the most recent from August 2022 to August 2023, according to the Department of Health. He had been accused of attacking a state hospital employee while he was a patient there in 2020 and pleaded guilty to third-degree assault in 2022, court records show.

Luke said Carvalho had been deemed stable enough to leave the hospital’s acute care unit and move to the state-operated specialized residential program, which is used to transition hospital patients into the community. Participants are allowed to leave the facility in the daytime.

But there were already signs the transition for Carvalho was not going smoothly. The hospital staffer said Carvalho is a “dual-diagnosis patient,” meaning he has a history of both mental illness and drug abuse, and Carvalho tested positive for cocaine use about a month ago.

That lapse landed him on probation-like status in his cottage, but did not cause him to be sent back to the secure facility, according to the staffer.

Luke dismissed the idea that Carvalho may have been deemed eligible to move into transitional housing too quickly in order to free up an in-patient bed.

“Patients go through a very thorough process to evaluate them and determine if they’re suitable for a different level of care,” he said. “For him to be in that level of care required that all of our clinicians determined him to be appropriately cared for in that setting.”

But, he said Department of Health officials were conducting a “clinical review” of the case.

A staffer for the hospital said the facility is also anticipating inspections or reviews by HIOSH, by the Joint Commission on Accreditation of Healthcare Organizations, and by the state Office of Health Care Assurance.

JCAHO is a nonprofit organization that accredits over 20,000 health care organizations and programs in the U.S., and OHCA licenses Hawaii health care facilities.

The hospital has three group homes on its campus including the one that housed Carvalho, and security at these facilities is not as robust as it is in the main, in-patient facilities, Luke said. The hospital has around 20 security guards on campus, but none were assigned to the residential programs, he said.

The state hospital has a troubled history with violence, but Luke said a staff member has never been killed before.

The hospital was the subject of a federal consent decree in the 1990s after a series of employee assaults on patients and the discovery of deplorable conditions within the facility, including stagnant pools of urine on the hospital floors, cockroaches in the kitchen and exposed pipes, nails and electrical wires that could be used as implements of suicide.

The facility implemented improvements and graduated from the consent decree in the mid-2000s, but the Senate launched a new investigation into the hospital in 2013 after employees came forward wtih stories of being assaulted by patients.

At the time, staffers complained that the hospital was ill-equipped to handle a new breed of patients who were coming to the facility via the court system. One employee in particular said then that over the course of his decade-long career he had been assaulted at least 60 times.

According to an annual report, there were 151 assaults on Hawaii State Hospital staff in fiscal year 2020, and 122 were reported the following year.

Luke said hospital officials are conducting a safety review after Monday’s incident and are seeking to increase staffing at the transitional housing program to seven people on the day and evening shifts instead of five. There are currently three staff members on the night shift, which Luke said he wants to increase to five.

Civil Beat reporter Nick Grube contributed to this report.