Veterans hospital policies for responding to violent patients scrutinized

Wednesday, May 29, 2013 | 9:07 p.m. CDT; updated 11:53 a.m. CDT, Thursday, May 30, 2013

COLUMBIA — Three hours after Robert Hill was assaulted Feb. 1 in a common room at Truman Veterans Hospital, Rudy Perez Jr. — the suspect in the case — was placed back in the same room with Hill.

Perez, 33, violently attacked Hill again, according to the probable cause statement. The statement describes him kneeling over Hill and striking him multiple times in the head. Hill, who was 78 years old, was taken to University Hospital for his injuries and pronounced dead four hours later.

Hospital's definitions for disruptive behavior

Here are the Truman Veterans Hospital's definitions for disruptive behavior.

  • Disruptive: any incident in which the delivery or care of services is interrupted or impeded.
  • Threat: any verbal or non-verbal expression of an intention to inflict pain or injury or to cause annoyance and alarm.
  • Violence: any physical force exerted to violate, damage or abuse another person, equipment or property.
  • Weapon: any instrument used to threaten or inflict bodily harm.

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According to Perez's attorney, David Tyson Smith, Perez had been in the veterans hospital seeking psychiatric treatment. He is a diagnosed schizophrenic and was off his medication when Hill was killed, Smith said after Perez’s first appearance in court.

In addition to the first-degree murder charge he is facing in Boone County, Perez — who is from Sedalia — is facing six charges in Pettis County related to a string of assaults in the week leading up to the Feb. 1 homicide. He is accused of assaulting his neighbor, a jail officer, and his parents on the way to the hospital to seek treatment. 

After Perez's parents were assaulted, an officer successfully petitioned a court to get Perez a 96-hour involuntary evaluation and treatment at Missouri Psychiatric Center, Pettis County Sheriff  Kevin Bond said. After Hill was killed, Perez was held at the Biggs Forensic Unit at Fulton State Hospital, Smith said.

The homicide happened on the second floor of the veterans hospital, where the psychiatric unit is located. 

The veterans hospital has repeatedly declined to answer questions about what happened the day Hill was killed, citing patient privacy laws and the ongoing investigation.

Documents provided by the hospital on its procedures for handling emergencies and aggregate incidents of violence over the past five years show that policies are in place at the hospital to handle disruptive patients. They don't specify ways to keep patients from further hurting each other or staff after a violent act. A March report from the VA Office of Inspector General, which looked at how disruptive patients are handled at several veterans hospitals throughout the country, found this to be a problem throughout the 140 hospitals in the U.S. surveyed for the report.

Truman Veterans Hospital was among the hospitals surveyed, said Office of Inspector General spokeswoman Catherine Gromek.

Preventing threats and acts of violence

From 2008 to 2012, there were 55 threats of violence by patients and 35 acts of violence by patients at Truman Veterans Hospital. No national database is kept of these incidents for the VA to see larger trends, according to the Inspector General's report.

Truman Veterans Hospital spokesman Stephen Gaither said violence is a reality in the facility, so the hospital has procedures in place to prevent it. According to a report by the Bureau of Justice Statistics, people who work in medicine — nurses, physicians, technicians and other medical personnel — are second only to law enforcement officers when it comes to being the victim of a violent incident.

“In the health care environment, threats and assaults are one of those risks people take,” he said.

Gaither wouldn't say if any staff members were injured in the incident in which Hill was killed in February, or the beating that preceded it.

Veterans hospitals have behavioral emergency committees to develop a method of alerting staff of disruptive patients and preventing incidents of violence. Each hospital designs its own policy and defines the role of its committee. However, the committee is not responsible for responding to incidents immediately, Gaither said. Instead, they are in place to deal with the aftermath and create new policies to make sure staff respond to violent or disruptive patients efficiently.

The hospital has its own police force that patrols outside in the parking lot and on the perimeter of the property as well as inside the hospital, Gaither said.

Staff must complete computerized training on how to handle disruptive and violent patients, though it's not required annually. It is the responsibility of the behavioral emergency committee to evaluate employees to make sure they have completed the training

Gaither said further hands-on training, which covers both self-defense and restraining patients, is offered to employees. The hospital does not have a certified instructor for hands-on training. The hospital's previous two instructors had left more than a year ago, but the hospital is looking to have someone on staff who can take their place, he said. Employees can go to other veterans hospitals to get the training if they want it, he said.

Flagging patients

When a patient makes a threat or exhibits other violent behavior in any of the veterans hospitals across the country, his file is flagged, and the next time he returns as a patient to a veterans hospital, he is supposed to check in or be escorted by police.

If someone has a violent history with civilian law enforcement, his file will not automatically be flagged unless he chooses to tell the hospital about it or another agency warns the hospital, Gaither said.

He would not say if Perez's file was flagged.

According to the Inspector General's report, the definition of disruptive behavior varies greatly from one hospital to another, so a patient might not be flagged in one hospital for an action another would deem violent or disruptive.

But even if a patient commits a violent act in the hospital, his file might not be flagged for a while. The report found that when violent or disruptive incidents happened, only 29 percent of the files of the patients involved were flagged within 10 days. Fifty days after the incident, that proportion rose to 40 percent.

The authors of the Inspector General's report recommended that the Under Secretary for Health consider ensuring that veterans hospitals "implement procedures to improve the timeliness of Category I (patient record flags) to alert (veterans hospital administration) employees to patients who may pose an immediate threat."

A Category I patient record flag is national and can be used to indicate that a patient may pose a threat to his or her own safety, or the safety of others.

Gaither said he did not have data on how quickly patients' files were flagged at Truman Veterans Hospital.

Handling immediate threats

When a patient poses an immediate threat to personal safety or property, hospital staff call a "code orange." Then, a page and an announcement are sent to VA police, nurses, psychologists, psychiatrists and social workers who have been trained to deal with disruptive or violent behavior, Gaither said.

He would not say whether a code orange was called Feb. 1 after Hill was assaulted.

Truman Veterans Hospital's policy doesn't specify what personnel should do immediately when a code orange is called, other than go to the location. But, according to the probable cause statement, when Perez was attacking Hill, a VA police officer pulled the men apart, Perez was restrained, and then hospital workers separated them.

VA police can restrain patients physically if they are being violent or disruptive, and the hospital also has two rooms in the psychiatric unit designed to physically restrain patients, Gaither said. He wouldn't say whether Perez was segregated in one of these rooms.

Arrest and prosecution is the only immediate response the committee designates. Warning letters, flags, police escorts during visits and restricted access to the facility for medical care are the long-term responses.

All of these would have been too late for an incident like the one in which Hill died. 

Perez is being held in the Boone County Jail and is scheduled to appear at a hearing in court Thursday. His attorney, Smith, filed a motion this week to have Perez transferred to Biggs Forensic Unit, pending the outcome of his court-ordered mental health examination.

Supervising editor is Katherine Reed.

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