Report Alleges St. Elizabeths Psychiatric Hospital Patient Abuse

Washington, D.C.’s only public psychiatric institution may have repeatedly violated D.C. laws regarding alleged employees’ treatment of mentally ill patients, including improper restraint and forced seclusion of patients, according to a report by nonprofit group Disability Rights D.C. at University Legal Services.

The report was published Sept. 26, two years after the federal government ceded control of St. Elizabeths Hospital to the local government. Disability Rights D.C. previously filed a lawsuit in 2005 in federal court suing for reforms on behalf of patients. The report cited repeated incidents in which hospital staff failed to employ proper de-escalation techniques with patients, exacerbating unsafe conditions in the hospital.

The 292-bed facility, located in Southwest D.C., was previously subject to seven years of federal oversight following complaints of overcrowding and assaults, which ended in 2014 after the hospital agreed to meet 224 benchmarks for care imposed by the Department of Justice. D.C. Department of Behavioral Health now oversees the hospital.

The authors of the report analyzed hospital records over a one-year period from May 2015 to April 2016. The records show 524 incidents of staff physically or mechanically restraining patients and 252 incidents of seclusion, though D.C. code 21-563 requires these measures be used only as a last resort.

Over the same period, hospital records counted 632 incidents of physical assault. The report pointed to poor staff conduct as a possible exacerbating factor in the high number of assaults.

“A significant reason for large numbers of acts of aggression may be the result of staff conduct — either because of staff conduct that escalates behaviors or staff’s failure to use techniques that deescalate behaviors,” the report reads.

In 2011, ULS previously settled a lawsuit filed in 2005 against the District of Columbia after alleging patients were not receiving appropriate psychiatric and medical treatment and staff shortages resulted in safety issues. As part of the settlement, St. Elizabeths agreed to improve open access to information about patient safety and allowed ULS to participate in routine monitoring visits.

ULS attorney Mary Nell Clark, who compiled the report, said she suspected hospital staff involved in cases of physical assault had not been following protocol.

“We did not find the evidence we felt like we should that they are using appropriate de-escalation techniques,” Clark said. “Maybe they are, but we doubt it.”

The report also details specific incidents of hospital staff apparently escalating or failing to appropriately de-escalate tense situations. In one case, a staff member identified as Staff One reacted explosively to a patient identified as Bill Mann, who reached out to touch his mother’s face during a visit.

“During the May 7th incident, Staff One threw his arm around Mr. Mann’s neck and tried to force him down, then grabbed Mr. Mann’s waist and pushed him backwards,” the report said. “After they fell, Staff One continued to hold Mr. Mann down on the floor. Staff One applied his body weight and appears to sit on or straddle Mr. Mann’s stomach, who was struggling on the floor.”

The report characterized the staff member’s conduct as “not simply abusive” and “extremely dangerous.”

DBH Legislative and Public Affairs Director Phyllis Jones declined to comment on what disciplinary action was taken regarding the staff member due to confidentiality concerns. However, she said the hospital takes disciplinary action against staff members when necessary.

“St. Elizabeth’s evaluates staff performance in incidents of alleged patient abuse to determine whether proper protocols and procedures were followed and will take action including additional training if needed, and disciplinary action up to dismissal when appropriate,” Jones wrote in an email to The Hoya.

The hospital’s internal report on the incident substantiated the allegations of physical abuse by the staff member. However, ULS said the hospital failed to recommend sufficient or significant corrective action in response to these findings. The St. Elizabeths report made only one recommendation — enforcing quicker response to the emergency call button.

“We are concerned that these measures do not address what may be a direct cause of the unsafe environment — the issue of staff’s response to agitated consumers and the adequacy of both the hospital’s training and the hospital’s support of staff required to meet the needs of individuals in care who present extremely persistent and challenging behaviors,” the ULS report reads.

Jones also disputed that these incidents represent a larger systemic problem for the hospital.

“Consistent with its commitment to continuous improvement, the Hospital regularly reviews training program to ensure best practices,” Jones wrote. “All staff is required to take mandatory safety training. There is no evidence of repeated failures by staff to adhere to training protocols.”

The ULS report makes a number of recommendations to the DBH in response to its findings, including investigating staff practices and re-assessing staff training programs. It also called for a DBH investigation into the hospital.

“DBH should now perform its own investigation of St. Elizabeths Hospital to determine if there are systemic failures, including the failure to identify staff members whose behaviors are escalating aggression and who are failing to implement de-escalation techniques, resulting in the unsafe environment,” the ULS report reads.

Though Jones did not acknowledge systemic failures at St. Elizabeths, she said they will meet with ULS to discuss the recommendations of the report.

“A secure environment for patients and staff that is also therapeutic and fosters recovery is a top priority for the new Chief Executive Officer Mark Chastang,” Jones wrote. “We look for ways to make the hospital even safer for patients and staff and will meet with ULS to discuss its recommendations.”

Max Lee (NHS ’17), who has volunteered at St. Elizabeths since last spring, said he was surprised by findings of the report.

“In my experience, the staff at St. Elizabeths always treat volunteers and residents with respect and professionalism. I have not witnessed any behavior that might indicate abuse,” Lee said. “Allegations of abuse, especially in this context, should never be brushed aside or ignored.”

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