JAMESTOWN, N.D. — A unit once used to confine violent or disruptive patients at the North Dakota State Hospital was closed days before a penitentiary inmate with a record of multiple assaults attacked a hospital housekeeper.
That attack, on March 29, resulted in facial fractures, lacerations and dental injuries to the housekeeper and charges of attempted murder and two counts of felony assault by the patient-inmate, Jason Benefiel.
The confinement unit, called intensive care by state hospital staff and administrators, was closed on March 20 because of “accreditation survey requirements” by The Joint Commission, which temporarily withheld its seal of approval for the hospital as deficiencies were resolved.
Housekeeper Christin Eastman, who has been unable to return to work and continues to receive treatments suffered in the attack, believes that the closure of the confinement unit allowed the patient to roam freely in the unit where he attacked her while she was cleaning a restroom.
“I truly believe it was a result of recent changes from The Joint Commission regarding the use of the isolation area, and the negligence of staff on duty in that unit at the time of my attack,” she said.
The Joint Commission, which enforces care standards at hospitals, found deficiencies at the state hospital, including its use of seclusion and restraint, which are to be conservatively employed.
Since the unit closed, employees have been left in a vulnerable position, Eastman said.
Before, she said, “patients who posed a risk were normally locked up and monitored back in isolation and no staff was allowed to enter alone or without a radio.”
Hospital administrators have declined to talk about the assault, citing patient confidentiality among other reasons, but said additional safeguards have been put in place.
The state hospital regularly receives penitentiary inmates or parolees who, like Benefiel, are sent for psychiatric evaluation.
The number of prison inmates in the hospital fluctuates widely and can range from five to 20 per year, said Tom Eide, director of field services for the North Dakota Department of Human Services, who oversees the state hospital and human service centers.
Inmates or parolees sent from prisons to the hospital pose a challenge for hospital staff, a former administrator said in a report to the hospital’s governing board.
“One thing to note is the increase in clients referred or paroled from DOCR,” a reference to the Department of Corrections and Rehabilitation, Lincoln Coombs, a psychologist who formerly served as the state hospital’s quality manager, wrote to the hospital’s governing board in December 2017.
“These clients have more violent histories and require intense observation and behavior planning,” he wrote.
Hospital staff are instructed to find less restrictive ways to intervene, and use seclusion or restraints only in emergencies, officials said.
Policies regarding the proper use of seclusion and restraint have sparked a “cultural divide” at state hospitals, Coombs said in a report to the board in June 2018.
“As is the case with all state psychiatric hospitals, there are some inherent and unavoidable safety concerns,” Coombs wrote, adding that the hospital was reviewing its policies and practices.
“Many mental health professionals believe that a reduced use of seclusion and restraint results in less incidents,” he wrote. “However, others are under the belief that intervening promptly and consistently decreases the danger to staff and clients.”
The North Dakota State Hospital, Coombs added, “has developed a professional reputation as having a client-centered and recovery-oriented approach to reducing violence and therefore minimizing the need for seclusion and restraint.”
The North Dakota Highway Patrol, which has jurisdiction at the state hospital, has investigated 11 assault reports at the hospital so far this year involving staff and patients, said Capt. Bryan Niewand.
The state patrol took over all investigations at the state hospital this year. Last year, when jurisdiction was split with the Jamestown Police Department, state troopers investigated seven assaults, he said.
Jamestown police last year investigated 10 simple assaults and one felony assault last year at the state hospital, Police Chief Scott Edinger said. Assaults investigated by police at the hospital have ranged from five in 2009 to 30 in 2013, he said.
Incidents that don’t rise to the level of criminal assault are reported internally by state hospital employees. Over the past three years, 38 incidents involving security officers were reported, according to records provided to The Forum through an open records request.
Those reports included employees being scratched, spit on, bitten and kicked. One employee, who last year suffered a knee injury, was taken to the emergency room. Most, however, received first aid, according to the reports.
The incident reports that were provided to The Forum didn’t appear to include any of the assaults reported to police or state troopers. The Forum had requested all reports over the past three years filed by or involving security officers at the state hospital.
Among more serious assaults, besides the assault on Eastman, a patient struck a hospital employee in June in a disagreement over the ability to have a water bottle on the unit, causing the employee to “stagger back” and become unconscious, collapsing to the floor, according to court records.
The patient, Jared Ray Halonen, faces arraignment and a preliminary hearing for felony and simple assault, according to court records.
In another case, in December 2016, an employee suffered a broken nose and broken eyeglasses in a felony assault, according to court records.
A staff member told a patient, Dwayne Julius Kimbrough, that it was time to take his medications. While walking down a hallway to receive his medications, Kimbrough abruptly turned and struck the employee in the face, sending him to the floor and breaking his nose.
Kimbrough, who served 330 days in prison for the assault, told police that he was in a bad mood and didn’t like the way the employee had asked him. Kimbrough was responsible for multiple attacks, staff members told police.
Employees at the North Dakota State Hospital have anonymously written news organizations and public officials, including Gov. Doug Burgum, to highlight what they say are unsafe conditions in the hospital and complain about the administration’s failure to address those concerns. In an online petition, the employees are seeking the removal of the hospital's top two administrators.
“We are sick of fighting for our lives over here,” an employee wrote in an anonymous email sent June 21 to Burgum’s office and obtained by The Forum. “We can’t keep staff and no one wants to work here due to the assaults and fearing for lives.”
Rosalie Etherington, the hospital’s superintendent, was not available for an interview for this article. Her staff, however, provided a list of steps that have been taken in the past six months to improve safety and security measures, including:
Zoned staffing, which spreads staff among patients so they can monitor situations and respond quickly.
Radios now have been issued to all staff on two of the highest acuity units, including the one where Eastman was attacked.
Camera observation training for all staff on the two high-acuity units.
Emergency response drills now are “formalized and centralized with the creation of the Emergency Management Committee.” Emergency response management drills have increased.
Daily meetings by the director of nursing with nurse managers to “review ideas, solicit feedback and organize change.”
The state hospital also is consulting with The Joint Commission and National Research Institute to make safety improvements. A team from the research institute will conduct a "thorough review of data to understand the patient population, characteristics that are common among patients committing the most egregious violent acts, and other relevant trends over time," according to a report presented to the hospital board earlier this month.
"The physical environment of care and unit layout will be examined to determine if there are contributory factors that can be altered," the report said.
The hospital’s former intensive care unit area is still being used, but methods have changed, Eide said.
“It’s not as restrictive as before,” he said.
Is it possible that it isn’t as safe?
“I would never say that,” Eide said.
Reports of assaults at the hospital have declined in recent years, according to figures compiled by the hospital, a trend that is mirrored by a decline in worker’s compensation claims at the hospital, Eide said. “Those two things correlating gives us a third party,” and suggests assaults are going down and are not just not being reported by staff, he said.
Since 2016, less than a quarter of reported assaults have resulted in reported staff injuries, according to hospital figures. In 2016, for example, when there were 110 reported assaults, there were 29 reported staff injuries.
Assaults against staff in recent years peaked in 2015 with 137 reported incidents, which had dropped to 89 reports last year. Eastman and her sister, Jessie Mead, a former nursing assistant at the state hospital, as well as an online petition raising safety concerns said some employees stopped reporting assaults because no action was taken.
Carlotta McCleary, executive director of Mental Health America in North Dakota and a member of the state hospital’s governing board, said there is a balance to be struck in the use of seclusion and restraint.
“Seclusion and restraint can be traumatizing for individuals,” she said. “It is something that you have to have really good policies around. You really do want to limit the amount of seclusion and restraint.”
Some state hospitals have forensic units, which treat disordered patients in a controlled environment. That’s an idea McCleary said she was willing to have the board explore.
“I would like to hear more and see the concerns from the staff as well as what the hospital administration is doing,” she said.
Sen. Kathy Hogan, D-Fargo, spent her career in human services and social services. Early on, 50 years ago, she worked as an aide at the state hospital and was struck in the face without warning by a patient who passed her in a hallway, breaking her nose.
“I just happened to be at the wrong place at the wrong time,” she said. Unexpected outbursts from patients will always happen at psychiatric hospitals and other settings, including nursing homes, Hogan said.
“A lot of it’s very difficult to predict,” she said, which makes proper training, including de-escalation techniques, critical. “That’s the challenge.”
Turnover at the state hospital is high, exceeding 20 percent annual rates in recent years. “The turnover rate is high because it’s really hard work,” Hogan said. “These are high-risk jobs.”
The challenges at the state hospital, where the census runs at almost 100 percent but shifts often are staffed at about 85 percent, according to reports given to the hospital board, reflect the ongoing crisis in mental health services in North Dakota, Hogan said.
“I think the overall lack of mental health treatment means people get much sicker before they get help,” especially given the lack of community-based services, she said. “I think what we’re seeing is decades of lack of services, so people escalate and escalate and escalate.”
She added: “This is a symptom of the behavioral health crisis in the state of North Dakota and it’s not just at the state hospital — it’s in every jail, every hospital.”