State of unrest

Lydia Lopez is used to spending the bulk of her time in hospitals.

For the last 15 years, the 62-year-old Lopez has cared for mentally ill patients as a psychiatric nursing aide at San Antonio State Hospital (SASH), one of 10 mental-health facilities within the Texas Department of State Health Services system.

These days, however, Lopez finds herself in the uncomfortable position of being a patient, not a caregiver. After a short stint at Brooke Army Medical Center, she is confined to a rehab facility, recovering from surgery on her back and wrist. The neck brace she wears around the clock tilts her head up so that she’s perpetually gazing at the ceiling, and causes such discomfort that she only sleeps two or three hours a night. Doctors installed a metal plate in her right wrist and two screws in her upper back to keep her vertebrae in place.

On the morning of June 14, a patient in the State Hospital’s forensic unit brutally attacked Lopez, punching her head repeatedly and hitting her with such force that she bounced off a wall.

Lopez considers herself lucky to be alive, given the harrowing beating she suffered. But her thankfulness is tempered by a sense that the attack might have been prevented if the mental-health facility was not chronically understaffed. She says that at the time of the incident, she was essentially the only staffer making rounds on the hospital’s first floor, handling patients who are regarded as violent or have been charged with criminal behavior.

“We almost always work short like that, and it puts us in a very dangerous situation,” Lopez says. “I have been harping about this forever, but, you know, I’m just a peon. Some of the nurses would tell `administrators` we needed help, but when they didn’t have enough, there was nothing they could do.

“There were even times when I would ask the permission of my supervisor to bring people in, because we were going to be short. But then the on-duty nurse would pull from us to staff other units, because they didn’t have enough people either. And it would leave us in a bad situation. It’s gotten much worse. They just can’t keep people.”

Research examining the mental-health industry in Texas supports Lopez’s complaints. In 2007, the Austin-based Hogg Foundation for Mental Health released the results of a study examining the state’s MHMR workforce, and found “critical mental-health workforce issues” and “extensive problems in recruitment and retention.”

“It is a major problem in Texas and also across the United States,” says Merrell Foote, communications director for the Hogg Foundation. “We just need to have more people going into the field of mental health. Mental health and mental illness carry a stigma, and that stigma can sometimes impact people’s decisions on what field they’re going to go into, if they’re interested in health care.”

In January 2008, the U.S. Department of Health and Human Services designated 184 of 254 counties in Texas as Health Professional Shortage Areas for medical health. Two years earlier, the Department of State Health Services reported an alarming 20.3-percent turnover rate among Texas psychiatric nurses.

More specifically, the San Antonio wing of the state’s mental-health system has historical problems with adequate staffing and the quality of its care. San Antonio State School, a facility adjacent to the State Hospital, houses patients with mental disabilities, and an Express-News investigation early this year found that the facility had the highest rate of confirmed abuse and neglect cases in Texas last year.

The staffing issue has long been sensitive for SASH because the hospital was one of the targets of a groundbreaking 1974 class-action suit, RAJ v. Gilbert, which decried horrific overcrowding at state mental-health facilities. The case resulted in a court order requiring SASH to address the overcrowding issue and improve its staff-to-patient ratio. The hospital reports that its patient population steadily dropped from a daily average of 2,700 in 1967 to 489 in 1992.

Lopez recounts her attack with the matter-of-fact directness of a health-industry veteran. She tears up only at the thought that her daughter, Anita, an Army Staff Sergeant who deployed to Iraq in late July, will worry about her. A widow for 18 years, Lopez doesn’t know who will take care of her when she’s released from Remington Medical Resort, a rehab facility about a mile north of the Medical Center. She’s scheduled to be released this week, but hopes that doctors will grant her an extension.

Lopez says that at 11 a.m. on Sunday, June 14, she was making her rounds when she came upon a patient — a muscular man in his late 20s who’d been transferred from the maximum-security facility in Vernon — acting suspiciously. Technically, there were three other psychiatric aides working the first floor, but Lopez says most of the patient-care burden fell on her.

“One of them was on light duty, which meant that he couldn’t have any direct patient contact,” she says. “There was another gentleman who was on a one-to-one, which meant that he couldn’t be away from his one patient. Then, there was one young lady at lunch.”

Lopez says that at the time of her attack, the only other staffer working on the floor was a registered nurse, dealing with paperwork in her office. “So I was the only one on the floor with 16 patients, but that’s par for the course. It happens all the time.”

Lopez noticed that the suspicious patient was hiding something in his hand. When she asked him what it was, he simply smiled and said, “Nothing.” She asked to see what he was hiding, and he turned as if he planned to comply. Instead, he started “wailing away” at the top of her head. In an effort to protect herself, she covered her face with her right hand, and suffered a fractured wrist.

The attack grew so furious that Lopez bounced off the wall. At that very moment, she says she heard a patient in a neighboring cubicle hollering for help. A nurse came down the hall and found the assailant calmly sitting on his bed. Lopez says a nurse later informed her that the assailant had been hiding a marijuana stash.

Hospital staffers took Lopez to the staff break room, and when a doctor examined her, he insisted that she be taken to Southeast Baptist Hospital. Despite the fact that her neck was in excruciating pain, doctors at Southeast Baptist cleared her to go back to work, with restrictions, in three days. Unconvinced, she checked into BAMC the next morning, and after stabilizing her neck, doctors determined that she’d suffered a neck fracture. Two days later, they performed surgery on her.

Lopez’s condition has slowly improved at the rehab facility, but on Friday, July 31, an examination at Fort Sam determined that the bones in her neck were not fusing properly, and doctors have prescribed her a bone stimulator to aid in the healing process.

Lopez says that SASH Director Robert Arispe has not contacted her since the attack occurred. The Current attempted to interview Arispe, but hospital officials requested that we submit questions for him in email form. After receiving the questions, SASH officials concluded “at this time, it would be inappropriate for us to comment.”

At the time of the attack, Lopez was less than a year away from retirement eligibility, and she frets that her rehabilitation is eating up the vacation and sick time she’d been saving to speed up her retirement. She says she’s not seeking a settlement from SASH, but would like her file to be kept open in case further complications emerge that require additional medical treatment.

In addition to her own recovery, she says the big concern for her now is preventing a similar attack from happening at the State Hospital.

“They say there’s always strength in numbers,” Lopez says. “If they know that someone’s going to come to your rescue, or you can make your rounds in twos instead of by yourself, that makes a big difference. If someone’s going to attack you, that other person can holler for help or come to your rescue.”

Beth Mitchell, senior managing attorney with the Texas watchdog group Advocacy, Inc., says the kind of staffing shortages described by
Lopez raise red flags about the adequacy of care at SASH.

“We do have a shortage at the State Hospitals, and I actually think that the State School problem contributed to that, because the legislature gave people who worked at the State School more money, so a lot of people who were at the State Hospitals moved over to the State School, because they could get paid more there,” she says.

It’s a problem that’s likely to intensify in the coming years. The Hogg Foundation’s 2007 study concluded that “the supply gap in mental-health providers is likely to become even wider in the near future as the aging workforce begins to retire and fewer people are entering the profession.”

Lopez is part of that aging workforce, and she worries about the future of the State Hospital.

“What happened to me, happened,” she says. “There’s nothing that can be done about that. But I don’t want even my worst enemy to go through this. I was lucky, because I’m alive. The other guy might not be so lucky.”