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A patient who had been discharged from the Hawaii State Hospital but was living in transitional housing on the hospital grounds is accused of fatally stabbing a nurse in what an official called an “unanticipated and unprovoked incident.”

Tommy Kekoa Carvalho, 25, who was arrested and booked on second-degree murder charge Monday night, had been deemed stable enough to leave the hospital’s acute care unit and move to a “State Operated Specialized Residential Program” in August.

State hospital Administrator Kenneth Luke said Carvalho had lived “successfully” in the residential program, which allows discharged patients to come and go from the hospital’s campus, before Monday night’s attack.

“We did not see evidence that this was going to happen,” Luke said during a news conference Tuesday at the Department of Health headquarters. He added that the suspect had been allowed to leave the facility earlier that day.

The slain nurse was identified as 29-year-old Justin Bautista. Bautista, who had worked for the hospital for four years, was “well respected and well loved,” Luke said. 

Bautista was a licensed practical nurse making an annual salary between $48,288 to $52,152 in fiscal year 2022, according to Civil Beat’s public salary database.

First Staff Member Killed

He was the first staff member to be killed at the facility, officials said, although it has a history of violence both against patients and employees.

The Honolulu Emergency Medical Services responded to the facility in Kaneohe at around 5:15 p.m. Monday and found the nurse with multiple stab wounds, according to EMS spokeswoman Shayne Enright. He was pronounced dead at the scene, Enright said.

The suspect also suffered a minor injury and was transported to an emergency room at another facility in the area.

Correction: An earlier version of this story said that the nurse was taken to the hospital and that another employee had suffered a minor injury.

The hospital officials referred questions about what type of weapon Carvalho used and how he acquired to the Honolulu Police Department. HPD spokeswoman Michelle Yu declined to answer questions about the weapon, citing the ongoing investigation.

Carvalho had been ordered to the Hawaii State Hospital four times. The last hospitalization was between August 2022 and August 2023, according to the Department of Health.

He was accused of attacking a state hospital employee while he was a patient there in 2020 and pleaded guilty to third-degree assault in 2022, court records show.

Luke said this was taken into consideration when Carvalho’s eligibility for transition out of the hospital’s acute care facility was being evaluated. It was one of the reasons that he was placed in a supervised residential program rather than back into the community, Luke said.

“This seemed to be an unanticipated and unprovoked incident,” he said.

Eligibility for release is determined by a panel of around six psychologists and psychiatrists who work independently of the state hospital and are trained to look at criminal risk, Luke said.

Luke described the residential program Carvalho was in as a kind of “bridge” for patients who no longer need to be in the hospital but require additional support before moving back into the community. The hospital also has three group homes on its campus.

Transition Program

Security at these facilities is not as robust as it is in the main, in-patient facilities, he said. The hospital has around 20 security guards on campus, but none were assigned to the residential programs, he said.

When asked if the hospital was considering changing this he said it was “on the table.”

The specialized residential program has space for 22 residents and had 21 people living there as of Monday, according to Department of Health Director Kenneth Fink. It was also fully staffed with five employees, including three psychiatric technicians, one registered nurse and one licensed practical nurse (Bautista),” according to the DOH. 

The state hospital’s in-patient facilities, though, which include a new 144-bed facility that opened in 2021 and a lower campus, are over capacity.

The hospital’s original license is for 297 patients, and there are 325 living there now, Luke said, adding that the state has a temporary authorization to care for up to 350 patients.

“Everybody’s in a bed, everybody’s staffed,” he said.

Those figures do not include people living in the supervised residential program or group homes.

Luke dismissed the idea that Carvalho may have been deemed eligible to move into transitional housing too quickly in order to free up an in-patient bed.

“Patients go through a very thorough process to evaluate them and determine if they’re suitable for a different level of care,” he said. “For him to be in that level of care required that all of our clinicians determined him to be appropriately cared for in that setting.”

But, he said Department of Health officials were conducting a “clinical review” of the case.

He also said he didn’t want the incident to lead to more patients being kept longer in hospital settings when are they ready to leave.

“If this tragedy stops individuals from being transitioned to the proper level of care, if it ends up with people left to be institutionalized in the state hospital, then it’s a double tragedy,” he said. “We cannot let this get in the way of appropriate transitions.”

Troubled History

The state hospital has a troubled history with violence, though Luke said a staff member has never been killed before Monday.

The hospital was the subject of a federal consent decree in the 1990s after a series of employee assaults on patients and the discovery of deplorable conditions within the facility, including stagnant pools of urine on the hospital floors, cockroaches in the kitchen and exposed pipes, nails and electrical wires that could be used as implements of suicide.

The facility implemented improvements and graduated from the consent decree in the mid-2000s, but the Senate launched a new investigation into the hospital in 2013 after employees came forward wtih stories of being assaulted by patients.

At the time, staffers complained that the hospital was ill-equipped to handle a new breed of patients who were coming to the facility via the court system. One employee in particular said then that over the course of his decade-long career he had been assaulted at least 60 times.

Scott Miscovich is a Kaneohe-based doctor who has treated several Hawaii State Hospital employees for injuries sustained after attacks by patients, including those that came forward in 2013 to recount the violence before state lawmakers.

Miscovich noted that those workers were often greeted with silence when expressing their concerns to administrators, which is why they ultimately decided to blow the whistle.

The recent attack, he said, only serves as a reminder that maybe not all the problems at the state hospital have been solved at least when it comes to worker safety.

“There has to be a review of the policies and procedures for protecting all the employees and all of the workers, especially those who are working with the patients,” Miscovich said.

According to an annual report, there were 151 assaults on Hawaii State Hospital staff in fiscal year 2020, and 122 were reported the following year.

Luke said that hospital officials are conducting a safety review after Monday’s incident and are seeking to increasing staffing at the transitional housing program to seven people on the day and evening shifts instead of five. There are currently three staff members on the night shift, which Luke said he wants to increase to five.