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Less than two years after the new $160 million Hawaii State Hospital opened, it is routinely overflowing with so many court-ordered admissions that patients are placed in beds in classrooms and other portions of the facility not meant for housing, according to hospital staff.

The fatal stabbing of a 29-year-old nurse at the state-run hospital on Monday is focusing new attention on the operations and safety of the new facility, which was built following a 2013 investigation into assaults and complaints that the old building was ill-equipped to handle a new breed of patients ordered there by the courts.

However, two staff members who discussed conditions at the hospital on condition of anonymity due to concerns for their jobs say overcrowding is a chronic, dangerous problem.

“It’s getting so crowded they’re bumping elbows and starting to get mad at each other, and mad at staff, and that’s kind of how it is here,” said one longtime employee.

Justin Bautista, a licensed practical nurse, was stabbed to death by a patient at the supervised transitional housing site, prosecutors say. It was the first time a state hospital staff member was killed on the hospital campus in Kaneohe despite a long history of violence and other problems.

The state-operated specialized residential program is based in cottages just outside the new secure facility, and hospital officials say the cottages were not overcrowded.

But hospital officials acknowledge overcrowding is a concern in the main hospital facilities — including the new building. State Department of Health data shows the state hospital has admitted more patients than it has discharged over the past decade. 

In fiscal year 2022, the hospital experienced a 45% spike in admissions over the previous year, from 229 to 333. In contrast, the hospital only reported discharging 275 patients, a net gain of 58 patients that year.

Of the 333 patients admitted to the hospital, 185, or about 56%, were committed through the courts after facing a felony charge.

Spike In Admissions

In a  to the Hawaii Legislature, the DOH said new units were able to accommodate some of the increase in admissions while the remaining patients were “absorbed” into the existing state hospital facilities.

The state hospital also has a contract for eight patient beds in a South Carolina facility for patients who cannot be treated in-state due to “intractable dangerous behaviors that present an unacceptable risk to the safety of other patients and staff.”

But during a press conference on Tuesday following Bautista’s death, Hawaii State Hospital Administrator Kenneth Luke said that “the census is something that worries me.”

“There’s only so crowded we can be before it does become a safety issue. But it’s on our radar, we’re doing everything we can to reduce the census,” he said.

Despite the overcrowding, Luke said the hospital is not improperly releasing patients before they are ready to return to the community.

He said the suspect, Tommy Kekoa Carvalho, had responded to treatment and was cleared to be discharged from the highly secure main facility by a clinical team that determined he was ready.

Carvalho was indicted on a charge of second-degree murder in Bautista’s death and is being held without bail at the Oahu Community Correctional Center ahead of an arraignment on Monday.

Luke said the hospital’s original license is for 297 patients, but the facility is over capacity with 325. He said the state has temporary authorization to care for a total of up to 350 patients in the older sections of the hospital as well as the new 144-bed facility that opened in 2021.

Luke replied that “we’re over the 297 that historically has been our license, but everybody has a bed, everybody is staffed.”

Finding Space In Unconventional Places

However, staff members said those beds for patients have been placed in some unconventional locations to cope with overcrowding.

That includes recreational therapy rooms — which are essentially classrooms — and conference rooms that are supposed to be used for meetings and remote appearances for court hearings.

Even seclusion rooms, or quiet rooms, are sometimes used to cope with the patient overflow, “which is not good because we need those rooms for emergencies, like if we have to restrain somebody,” said one staffer. “That’s what the seclusion rooms are for.”

Beds also have been placed in grooming rooms, which are equipped with sinks and are supposed to be used for shaving and similar activities, as well as so-called sensory rooms adjoining the hallways outside of the main units of the hospital.

“They’re already hunting and sending teams through the hospital looking for places they can stuff people,” another staffer said.

The problem tends to be aggravated on Fridays as the courts commit more prisoners to the custody of the state Department of Health for treatment of mental illnesses, staff said.

Luke said Tuesday the new hospital building is “highly secured, highly staffed.” The health department declined a request for an interview with Luke to discuss more details.

Troubled History

The Hawaii State Hospital has struggled for years with overcrowding and a lack of adequate staffing. 

In 1991, the U.S. Justice Department forced the state to improve conditions at the hospital via a court-ordered consent decree after inspectors found a litany of problems within the facility, including overmedication and unsanitary conditions. There were cockroaches in the kitchen and the investigators said they were forced to navigate around “numerous puddles of urine.” 

The hospital was at maximum capacity in 2014 when the Hawaii State Senate launched an investigation into patient attacks on staff at the facility. 

At the time, hospital statistics showed that staff were suffering attacks at least once every three days. One staffer in particular had reported being attacked nearly 70 times over the course of a decade-long career. 

According to the committee, the hospital was designed and budgeted to house 168 patients on any given day, but it . The hospital also had a contract with a private psychiatric hospital, Kahi Mohala Behavioral Health, for an additional 40 beds, which only added to the overall overflow numbers. 

When combining those figures, the committee found that the hospital often exceeded its daily census by 70 patients, or about 42% above what was budgeted.

Hawaii Gov. Josh Green was a senator in 2014 and one of the co-chairs of the committee that spearheaded the investigation. He’s also a medical doctor.

Looking Ahead

Despite the $160 million the state spent on a new state hospital, Green acknowledged more needs to be done because it’s clear that facility already has reached its limits. 

He noted that in general mental and behavioral health services in Hawaii are lacking, especially as mental illness and drug abuse, which can exacerbate psychosis, are on the rise.

“It’s challenging because we don’t have enough beds or providers at any level,” Green said. 

The governor announced a $30 million loan repayment program in September as a means to recruit more medical workers to Hawaii, including those focused on mental health and substance abuse. He said that will only address part of the problem. 

There’s still a need to increase capacity to relieve pressure on the Hawaii State Hospital, which has been forced to evolve into a forensic facility that treats a wide range of patients, some of whom, like Carvalho, have displayed a propensity for violence. 

One solution, Green said, could be found in the construction of a new jail. 

“My feeling is that it needs to have a lot of capacity to treat addiction and mental illness in a controlled setting,” he said. “That way the state hospital becomes more of a place to treat actual mental illness and not just a place to treat violent drug addiction.”