The union for workers at the Hawai'i State Hospital is calling for state officials to address safety concerns at the Kane'ohe psychiatric facility following three serious assaults by patients on staff, including one last month in which a 62-year-old occupational therapist was struck in the head repeatedly with a large padlock.

A grievance was filed in March by the Hawaii Government Employees Association in the wake of two of the assaults, which officials say were directed at psychiatrists and required emergency- room visits. The third assault occurred May 20, when 21-year-old patient Mark Davis, known for his violent outbursts, allegedly attacked the occupational therapist.

The therapist, who was helping another patient when the attack occurred, was struck four times in the head with the padlock and once in the arm.

Davis was arrested on suspicion of second-degree assault but has not yet been charged, police said.

Some advocates and lawmakers say the alleged assault involving Davis in particular raises questions about whether the Hawai'i State Hospital is equipped to handle mentally ill people who have committed heinous crimes and have a history of violent behavior — potentially posing a threat to hospital staff and the surrounding community.

Davis was 14 in 2001 when he stalked, sexually assaulted and killed a 6-year-old girl in an abandoned home in a Big Island subdivision. Davis admitted the killing in 2005, the same year he was committed to the state hospital and later escaped from the facility after getting angry at a nurse. He was found within hours in a canal in front of Temple Valley Shopping Center.

Over the years, according to court documents, Davis has attacked staff and patients repeatedly. In June 2006, he was transferred to a facility in California but was returned to Hawai'i the next month after California officials said he committed more than two dozen assaults and attempted to escape — getting as far as a parking lot, where he tried to hot-wire a car.

One Hawai'i State Hospital psychiatrist said in a July 2008 document filed with the court that "every day with this patient is a struggle" and warned that Davis "believes that if he hurts enough people," he will be moved to another facility.

THREE ATTACKS

The three serious assaults so far this year on Hawai'i State Hospital staff compare to two in all of 2008.

A source said the three attacks since January all involved different patients.

Nora Nomura, HGEA deputy director for field services, said the attacks have staff "feeling that this is not a good situation." The union represents about 309 of the 688 employees at the state hospital, including 150 nurses and 89 social workers, therapists and other health care professionals. There are 185 patients in the facility.

Nomura said the union is looking into what happened in the attacks to see how they could have been prevented. She said the assaults are especially worrisome for staff at the facility given the prospect of worker furloughs, which could reduce the ratio of direct-service workers to patients on some days.

Requests for comment from the director of the Hawai'i State Hospital were referred to the state Health Department, which oversees the facility.

Health Department officials said they also are investigating the assaults.

They declined to discuss specifics of the incidents, citing patient confidentiality. But in an e-mail, Health Department spokeswoman Janice Okubo said that "the goal of Hawai'i State Hospital is fewer assaults and no injuries." She added, "we review every assault and attempt intensively and change our practice as needed."

In addition to the three serious assaults this year, the hospital said it has had 65 other assaults on workers by patients. Those assaults ranged from bodily harm that required basic first aid to actions such as verbal insults, spitting and threats. In 2008, there were 150 attacks on staff, compared to 179 in 2007.

LAWMAKERS WORRIED

The issue of assaults on staff at the Hawai'i State Hospital - the only public institution in the Islands for the mentally ill — has come up before. In 2007, concerns from hospital workers prompted lawmakers to tour the facility. At the time, the hospital had 201 patients and a $6.5 million deficit that had forced it to release about 50 workers.

State Sen. Clayton Hee, D-23rd (Kane'ohe, Kahuku), was one of the legislators concerned about the assaults on staff two years ago. He said the three serious assaults this year raise questions about safety precautions in place at the hospital. And he added the situation could get worse if workers at the facility are furloughed.

He also said the incidents shed light on what he considers a larger problem: the lack of a separate state facility for mentally ill people who have shown violent tendencies. He said advocates and lawmakers have long said that the mentally ill who are considered dangerous should be held separately from those who are not violent.

There are no immediate plans to build such a facility.

But the Health Department did say it is adding a "psychiatric intensive-care unit" on the grounds of the hospital to handle patients who exhibit "challenging behaviors which cannot be effectively managed elsewhere in the hospital."

Work on the new unit will start in December, and it is expected to open in May 2010. The new unit will cost about $550,000, and will be able to hold four patients.

Okubo said it will have a higher patient-to-staff ratio than the rest of the hospital.

NO EASY ANSWER

About 99 percent of patients at the state hospital are referrals from criminal courts, and their charges range from misdemeanors or violating the terms of their release to violent crimes.

In fiscal year 2007, the hospital saw 226 new patients. Of the 93 people admitted for felonies, 61 had been committed for crimes "against a person." The other felony admissions were for property crimes, according to a report to the Legislature.

The Rev. Mike Young, who was on the Hawai'i State Hospital's patient protection committee in the 1990s and recently stepped down, said there is no easy answer to the question of what to do with violent patients. He said the hospital is designed to deal with the majority of patients, who are not regularly violent and who respond to their treatment.

"Do you create another institution that's designed to deal with emotionally unstable violent people who otherwise would have been convicted of a serious crime?" asked Young. "I don't know what the answer is."

Court documents show that Davis, who has mild mental retardation, is diagnosed with intermittent explosive disorder and antisocial personality disorder and is on a host of medications.

In June 2006, court documents show, he was sent to a rehabilitation center in California, which reported he assaulted staff and patients 27 times in six weeks. He also attempted to escape by doing a "front flip onto the roof," running over the roof and then scrambling to the parking lot, where he tried to hot-wire a car, court documents said.

The rehabilitation center also said staff called in sick because they feared working with Davis.

A Hawai'i State Hospital-proposed treatment plan for Davis filed with the court in July 2008 said he has attacked staff numerous times, and has left two people on workers' compensation.

Dr. Michael Chang, staff psychiatrist at the hospital, said in the treatment plan that "every day with this patient is a struggle to keep the environment safe. He ... believes that if he hurts enough people that we will be more motivated to find him another facility. We need every tool possible that can contribute to a safer setting for the patient and staff."

Chang also said that Davis "has demonstrated sustained intractable violent behavior" and his outbursts are of "high lethality to himself and others."

Chang said in the treatment plan it is unlikely Davis will be transferred to an out-of-state facility.

The Health Department added that none of its adult mental-health clients are on the Mainland receiving treatment.

As of last week, Davis was still in the Hawai'i State Hospital, police said.

READINESS KEY

The occupational therapist injured in the May 20 assault was taken to Castle Medical Center and was released that evening. The padlock used in the assault was part of a kit that helps assess the cognitive abilities of patients.

The state Health Department declined to release a surveillance tape that shows the incident, citing patient privacy laws.

Marya Grambs, executive director of Mental Health America of Hawai'i, said Davis appears to be an extreme case but added that "the state hospital has several patients like that who have been found to have committed pretty vicious murders" and said the facility should be equipped to "handle this kind of situation."

She said if it's not, then that raises serious health and safety questions.

"A hospital which is 99 percent comprised of people who have committed some kind of a crime should have the ability to handle those few cases where there is this level of violence," she said.

Grambs also said despite the recent assaults, the state hospital is a far better facility than it was in the 1990s, when it was under U.S. Justice Department scrutiny because of deplorable conditions.

A 1991 civil rights lawsuit against the hospital spurred a consent decree that kicked off 15 years of federal oversight into the state's delivery of mental-health services and treatment. Federal oversight of the state hospital was lifted in 2008.