The licensed practical nurse role is being phased out in favor of more specialization.

The killing of Justin Bautista, a licensed practical nurse at the Hawaii State Hospital, has raised questions as to what exactly was expected of him in a typically lower-skilled role he had held for four years.

Bautista was licensed as a practical nurse by the state and had worked at the State Hospital since at least 2020, salary records show. Licensed practical nurses, or LPNs, are typically frontline providers in long-term care. They are considered generalists who develop specialization through experience gained on the job.

The Hawaii State Hospital almost exclusively functions as a forensic facility treating court-committed patients. But the hospital has faced overcrowding and staffing shortages.

Police Crime Scene tape marks an area at the Hawaii State Hospital Tuesday, Nov. 14, 2023, in Honolulu. A 29-year-old male was killed by multiple stab wounds at the hospital Monday. (Kevin Fujii/Civil Beat/2023)
Justin Bautista had approximately four years of experience at the Hawaii State Hospital where he was killed, salary records show. (Kevin Fujii/Civil Beat/2023)

Bautista’s fatal stabbing took place at the hospital’s supervised transitional housing unit, an unsecured outpatient area at the campus. It was the first time a staffer has died at the Kaneohe facility.

In an emailed statement, Department of Health spokesperson Rosemarie Bernardo-Grimes said the department believes security concerns at the main facility and at the outpatient area where Bautista was stabbed are separate issues.

She wrote that the state hospital typically maintains 51 security staff onsite within any 24-hour-period. “Be reassured that HSH does, and will continue to prioritize staff and patient safety at all its facilities, now, and into the future.”

Traditionally LPNs handle day-to-day direct care including administering medicine and providing prescribed treatments, and are often the face of care in long-term facilities. But always under the supervision of a registered nurse.

LPNs and RNs have similar roles as support staff, according to Nurse Journal, but RNs are more equipped for acute and emergency care.

Dan Ross, president of the Hawaii Nurses Association, said RNs have gradually taken over acute care because of the need to make medical assessments — something LPNs can’t do.

People with LPN-level training are also becoming scarcer, according to Ross, as health organizations opt for staff with more advanced training.

In 2019 there were 2,669 LPNs in the state — as of September 2023 there were 1,652, although not all work in the mental health field.

The difference in skills is reflected in pay.

Database updated: Feb. 8, 2024
Check back for updated public employee salaries for the 2024 fiscal year.

Note: For FY2024, identifying information for these UH Graduate Assistant positions has been redacted. By way of explanation, UH said that the university had reviewed its obligations under the Family Educational Rights and Privacy Act and determined that the students’ information could not be disclosed. The position and salary information is included to ensure the database is as complete as possible for comparison with previous years.

An LPN can make $58,440 compared to an RN’s $77,190 in a nursing home setting as a national average, according to the Bureau of Labor Statistics.

In Bautista’s case, salary data on Civil Beatʻs Public Employee Salary Database shows he made between $48,288 to $52,152 in 2022, a roughly 12% pay increase from the entry-level role he initially held.

It’s difficult to distinguish applicable roles at the state hospital since the health department did not provide a current staff roster in response to a request from Civil Beat.

According to the state’s 2022 compensation plan, an “LPN – Mental Health (FP)” like Bautista was considered a technician in an institutional, health or correctional environment.

“They’re not supposed to do the patient assessments,” Ross said, “LPN stands for practical nurse, so they go out there and do the practical hands-on things. But I think the theory is they don’t have the training for the level of critical thinking skills that RNs are supposed to have.”

New Job Description For A New Facility

A 2016 job listing for an LPN position at the state hospital — based on a job description written in 2006 — said the employee will provide medications, maintain patient records and assist physicians and nurses with treatment. It required an active LPN license, basic physiological knowledge, and one year of working experience for the entry-level tier position.

Warmth and compassion were also desired qualifications.

Six years later a posting for the same job opens with a stark description of the working conditions: “Many of the patients frequently exhibit extreme hostility (which may include violent behavior to others or themselves), may be confused, combative or are resistant to services … Work may involve dealing with violent outbursts, physical or verbal threats and assaults, and physically restraining patients.”

It also said that the hospital is Hawaii’s only acute care facility “dedicated solely to serving adults with serious mental illness.”

Prior to 2021 when a new facility opened, the aging Hawaii State Hospital consisted of buildings in need of repair. (Anita Hofschneider/Civil Beat/2021)

When the state opened the hospital’s new facility in 2021 it was reported that the administration planned to hire 100 more staffers. Yet according to a recent statement given by the health department, 140 positions — or about 20% of the workforce — are vacant.

Civil Beat previously reported that in 2022 the hospital’s admissions spiked to 333, with over 50% committed by court order. Hawaii State Hospital Administrator Kenneth Luke at the time said the hospital was over the limit of 297 patients mandated by the hospital’s license, but that the state had temporarily authorized up to 350.

The hospital has a long documented history of violence directed at staff; last year alone the hospital recorded 154 assaults and attempted assaults on employees, a decrease from a high of 234 in 2021.

LPNs, RNs and other state hospital staff are trained in conflict prevention, management and resolution skills to deescalate dangerous situations.

A 2014 senate investigation of the old facility found CPMR training inadequately prepared staff for the violent patients they oversaw. According to the report, all staff were given 10-hour training sessions and were supposed to have yearly follow-ups.

The DOH spokeswoman, Bernardo-Grimes, confirmed in an emailed statement that conflict training is required of all state hospital staff, including two mandatory drills each year for personnel that provide direct care to patients.

It remains unclear if the training adequately prepares them for the potentially confrontational patients the courts are committing.

The alleged assailant in Bautistaʻs death, Tommy Kekoa Carvalho, 25, was known known to be an aggressive and physically violent patient. He has been charged with second-degree murder.

Civil Beat’s community health coverage is supported by the Atherton Family Foundation, Swayne Family Fund of Hawaii Community Foundation, the Cooke Foundation and Papa Ola Lokahi.

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