Construction of a state-of-the-art psychiatric hospital was supposed to mark a new era in worker and patient safety. Instead, a familiar set of problems emerged.

Newly released documents and testimony from the Hawaii Labor Relations Board paint a troubling picture about work conditions at the Hawaii State Hospital and, in particular, its new $160 million forensic treatment facility that was designed to securely house some of the state’s most difficult and violent patients.

The records and testimony focus on a labor complaint filed by the Hawaii Government Employees Association against the state hospital in 2022 and reveal serious safety concerns about the new facility, some of which were described in detail by nurses and others working at the hospital.

Badge readers often malfunctioned, resulting in staff propping open doors with rubbish bins so that they could move throughout the facility. 

Janitors and others had unfettered access to the secure medication room, where narcotics were stored alongside potentially deadly weapons, including razors and pill cutters.

Nurses would find themselves locked inside seclusion rooms — sometimes with patients experiencing violent outbursts — because hardly any of them knew how to operate the doors from a centralized control station designed to improve security.

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)
The Hawaii State Hospital was the scene of a deadly attack earlier this month. (Kevin Fujii/Civil Beat/2023)

Michael Quinn, a nurse manager at the state-run facility, was among those who testified under oath before the labor board in April, according to recordings obtained by Civil Beat through a public records request. He was blunt in his assessment of the problems, pointing out that there were too many patients, not enough staff and very little training on how to operate the improved security systems.

“We’re winging it right now,” Quinn said. “It’s not really clear who’s in charge at the hospital.”

The staff have pleaded for help, but those pleas have fallen on “deaf ears,” he said. Rather, there’s been an effort to “keep quiet some of the inadequacies” so as not to raise alarm about the state of the new facility.

“We’re doing a good job of keeping a lid on things, but there’s an increasing frequency of risky situations,” Quinn told the labor board. “We’re really concerned that one day there’s going to be a bad incident, somebody getting maimed or killed or something. At some point our luck’s going to run out.”

Quinn’s comments were prescient.

The Hawaii State Hospital has come under increased scrutiny in recent weeks after a nurse there, 29-year-old Justin Bautista, was stabbed to death on Nov. 13 while working at a transitional care unit on the hospital campus.

“What’s been described is clearly unacceptable and we need to do something about it.”

State Sen. Joy San Buenaventura

Tommy Carvalho, 25, a patient who had demonstrated a history of aggression, has been charged with second-degree murder for Bautista’s killing.

Officials from the Hawaii Health Department, including Hospital Administrator Kenneth Luke, have promised a full inquiry into the assault but have also made clear that the attack occurred at a transitional facility outside of the new patient facility.

The Hawaii Department of Health, which oversees the state hospital, has declined numerous interview requests from Civil Beat since Bautista’s attack. 

In a written statement, a DOH spokesperson did not specifically address the allegations aired during the labor hearing. Luke and other health officials have insisted the patient facility is highly secure and safe for those working there.

A New Era In Safety?

The Hawaii State Hospital has struggled for years with safety and security. 

In 2014, the state Senate formed a special committee to investigate attacks on staff, which at the time were occurring about once every three days. The idea to build a new psychiatric hospital, one that could handle the ever increasing influx of patients committed by the criminal courts, including many who had been arrested for violent crimes, was born out of that inquiry. 

The Legislature approved the funds for the new facility in 2016 and patients began moving in during the spring of 2022 after a series of setbacks and construction delays that officials attributed to “careless mistakes.” 

The new four-story, 144-bed facility was equipped with hundreds of security cameras and was built in a way to reduce blind spots so that psychiatric technicians and nurses could keep a trained eye on more patients. A centralized security hub was supposed to help guards monitor the facility while opening and closing secure doors with the press of a button. 

The HGEA, however, was concerned that officials were rushing to open the facility without properly training its members, many of them nurses who had no experience working inside a forensic hospital.

In 2021, the union sought to delay the opening of the facility through the Hawaii Labor Relations Board but was ultimately unsuccessful. A year later it followed up with a prohibited practices complaint that resulted in the HLRB ruling that the hospital had in fact shirked its duties to consult with the union. 

The HRLB’s decision came after the HGEA presented reams of evidence that, the union argued, highlighted unsafe work conditions within the state hospital, some of which persist. 

Staffing was among the biggest concerns. The union submitted more than 50 employee incident reports filed by nurses working in the new facility who cited an “unsafe and chronic staffing shortage.” 

Each report was nearly identical and recounted the same complaint almost verbatim. 

“Severe and chronic shortage of staffing is a major health and safety concern for everyone, our patients and staff,” the nurses said. “Our patients are unpredictable which can lead to a crisis at any time. Our staff are trying their best to care and support our patients and each other, but we are burnt out. We need help.”

HGEA’s Executive Director Randy Perreira declined to comment.

‘The Staffing Is Horrendous’

The union relied upon the testimony of Quinn and others to help build its case before the labor board and the stories they told provided an unvarnished view of the struggles faced by many of the staff working at the Hawaii State Hospital. 

Josette Kawana, for instance, had worked for the hospital as a nurse for nearly 30 years. In sworn testimony, she said the training for staff assigned to the new forensic facility was meager. She also complained about the condition of the building itself. 

Kawana said there was political pressure to move into the new facility after years of delays, but that when patients first arrived the roof was leaking, the showers drained into the hallways and the water coming from in the drinking fountains ran hot instead of cold.

Images of trash cans holding open secured doors at the Hawaii State Hospital were included as exhibits in HGEA’s case before the state labor board. (HGEA)

Kawana said she was particularly concerned about the staffing ratios inside the new facility. 

During her testimony, she noted that on one occasion she and another nurse were forced to evacuate the hospital in the middle of the night for a fire alarm while keeping tabs on 26 patients, many of whom, she said, had criminal histories including drug use, sexual abuse and violence. 

“The staffing is horrendous,” Kawana said. “We’re short every day every shift.” 

She also worried that the private guards the hospital hired to operate the security doors and control entry into the facility were cutting corners and contributing to the safety lapses. 

Kawana described several instances where she set off the metal detectors when entering the new building. On occasion, she’ll get a pat down by the security guards, she said, but other times she’s allowed to walk through with little more than a glance. 

“They’ll just buzz you in,” she said.

Kawana recounted numerous scenarios in which doors would malfunction and nurses would get stuck inside elevators or locked in with a patient experiencing a dangerous episode.

She said she even filed complaints with the Hawaii Occupational Safety and Health Division, which launched an investigation and found that the hospital had violated the law by not providing proper training for staff. 

It’s unclear what state hospital officials have done to address the many problems described before the labor board. It’s also uncertain whether any of the safety or security issues found in the new patient facility are being experienced in other parts of the hospital campus, including the transitional housing unit where Bautista was killed.

DOH spokesperson Rosemarie Bernardo said the transitional housing unit where Bautista was killed is considered a stand-alone treatment facility from the state hospital even though it is located on the same campus. She also pointed out that the transitional treatment facility is “fully staffed.”

“We believe the concerns at HSH you raised and the incident at the residential program are separate and unrelated to each other,” Bernardo wrote in a statement. “Please be reassured that we do, and will continue to, prioritize staff and patient safety at all its facilities, now, and into the future.”

Bernardo added that since HGEA filed its complaint with the labor board that there have been changes in leadership both at DOH’s Adult Mental Health Division and at the Hawaii State Hospital.

State Sen. Joy San Buenaventura, chairwoman of the Health Committee, said it’s clear that more needs to be done to address the safety concerns at the state hospital and that begins with making sure there’s enough staff to handle the influx of patients.

She said the current staff vacancy rates — which DOH officials have said is around 20% — are troubling, particularly for a forensic hospital that’s supposed to treat patients sent by the courts.

“What’s been described is clearly unacceptable and we need to do something about it,” she said.

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