Inside Fulton State Hospital: Severe disrepair threatens patient care, safety

Friday, May 2, 2014 | 6:00 a.m. CDT; updated 11:35 a.m. CDT, Saturday, May 3, 2014
Laura Crandall, food service manager at Fulton State Hospital's dietary services, opens the door to the dietary center's deteriorating walk-in refrigerator. The hospital redesign plans call for a new kitchen located in the same building as patient wards.

FULTON — The pens, which can be checked out from the nurses’ station, are a relatively new feature.

They resemble normal ballpoint pens, like basic Bics. Clear body, so you can see the ink. No caps, though. And they’re shorter.


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The big difference? They’re completely flexible. You can tie one in a knot.

They take some practice to use. It’s hard to get enough pressure to make a mark when the whole thing wants to bend under the weight of your hand.

The pencils here are flexible, too. Regular wood pencils aren’t allowed. They present a security risk ­— a potential weapon or deadly item to swallow.

You can’t draw blood with flexible pens or pencils. And they pass fairly easily if swallowed.

The door handles are new, too. Each is situated in the usual place, on the door’s right panel, maybe 3 feet from the floor.

But each door also has a second lock in the middle, which opens a smaller door-within-a-door. If a patient barricades a door, nurses or security officers can still get inside the room.

The blue polyurethane bed frames, bolted to the center of each patient’s room, are new as well.

Just about everything else at Fulton State Hospital, however, is old. And by today’s standards for psychiatric care, dangerously so.

Fulton State Hospital sprawls across a 95-acre campus about 25 miles southeast of Columbia. It is the state’s largest in-patient psychiatric facility, once housing almost 2,500 patients in 38 buildings.

These days, after decades of change in psychiatric care and efforts to serve the mentally ill in local communities, just four of the buildings remain in use as residences for some 375 patients.

Most are mentally ill people accused of crimes and assigned here because they are deemed unfit to stand trial or were declared not guilty by reason of insanity. The hospital also houses a small unit of developmentally disabled people who got into scrapes with the law and 75 men from the state’s Sex Offender Rehabilitation and Treatment Services program.

As the state’s only maximum-security psychiatric hospital, Fulton State takes patients with no place else to go. They’re too violent for the state’s less-secure facilities, yet too ill for prison.

But the hospital, which has fallen in to disrepair over several decades, is a difficult place for patients to get well and a dangerous place for professionals to work.

Built before the Civil War

Fulton State Hospital was built in 1851 and was the first psychiatric hospital west of the Mississippi River. Its original building no longer exists, but decaying buildings that date back to the 1870s still dot the campus.

Biggs Forensic Center, the hospital’s largest unit at 186 beds, opened in 1940. Biggs was once state-of-the-art, but it hasn’t been maintained.

Paint is chipping. Chunks of ceiling tile are missing. The emergency exits, added years later when fire codes were developed, hang precariously from the side of the building.

Beyond cosmetics, the building’s layout isn’t up to par for safe, effective psychiatric treatment. The space’s narrow hallways and sharp corners create blind spots, which make it harder to spot attacks on patients or staff.

The risk to staff isn’t just theoretical: Worker’s compensation claims at the hospital are the highest in the state, at $4 million a year.

The issue before the legislature this session is not whether, but how to cover the cost, projected to be $211 million to build a new facility. 

The House on Tuesday passed a $400 million bond plan to be repaid over five years; it will now be considered by the Senate but also would require voter approval in the November election. It includes $200 million for the mental hospital.

Meanwhile, the Senate passed a bill earlier this legislative session that would raise the state’s cap on bond sales by $600 million to cover the hospital reconstruction and deferred maintenance at Fulton and other state facilities. The Senate version of the measure does not require voter approval.

Although the full funding remains unresolved, a $13 million redesign of Fulton State is already underway with bipartisan legislative support. 

Structural shortcomings

Marty Martin-Forman is Fulton State Hospital’s chief operating officer and a 34-year veteran here. To her, the hospital’s mission is clear: Help Missourians get well.

But in the facility’s current condition, it’s failing to meet patients’ most basic needs, she says.

“People don’t get well without natural light,” Martin-Forman says as she walks down a long, dim hallway in one of the hospital buildings.

The walk — one of many Martin-Forman leads for elected officials and reporters — takes visitors to Biggs Forensic Center, where most of the hospital’s patients live. Plans call for it to be torn down.

Entering Biggs requires a trip through a metal detector, where visitors surrender keys, phones and wire-bound notebooks. Employees returning from lunch break put their takeout containers through an X-ray machine. Security officers accompany visitors and staffers alike and monitor the building’s 188 cameras.

For all that security, Martin-Forman is quick to point out that Biggs is not a jail. Instead, the staff here works to get patients well enough to move them to the Guhleman Forensic Center, the hospital’s intermediate-security residence located across the street.

In hospital speak, Guhleman is a “step-down” facility for patients who become well enough to live in lower-security environments but are not yet well enough to leave the hospital entirely.

Fulton State focuses on long-term treatment; the average patient spends nearly three years here. Those who do leave usually head to other hospitals, rather than straight back to society. Martin-Forman says most of Fulton’s patients will need psychiatric care for the rest of their lives.

After passing through security at Biggs, heavy doors separating the lobby from patient and visiting quarters clank closed. But there’s a pause before hospital officials can travel any farther down the gray-tinged halls. Everything has to be manually locked by Martin-Forman, who carries a cumbersome ring of clunky keys.

Newer hospitals are keyless. Identification badges — which Fulton State Hospital employees already wear — can open locked doors with a quick swipe. The badges can be programmed to grant access to different parts of the hospital.

The swipe system cuts down on security risks. If a badge goes missing, its key card access can be disabled via computer. A missing key at Fulton requires the whole hospital to go into lockdown until the key is found.

Inside Biggs, the shortcomings are obvious. A security worker with a black padded arm guard — worn to deflect punches or bites — must be stationed outside the cracked, concrete showers to keep an eye on patients, who are invisible from the central nurses station.

The worker also monitors the hall for fights or attacks on staff.

In the wards, the nurses station is adjacent to the patients' common area. Patient rooms are separated from that community space and extend all the way down long hallways. If a fight breaks out in the patients' quarters farthest from the station, response time to incidents can be slow.

Fights between patients were reduced after the hospital tinted the windows in the nurses’ stations, which separate wards. Prior to the tinting, patients could communicate through the glass, sometimes coordinating attacks or riling up each other.

New patients are admitted in an open space next to the nurses’ station. The patient and an admitting doctor sit across from each other at a heavy wooden table in the middle of a ward.

The doctor asks the patient, who is often still wearing an orange prison jumpsuit, personal medical questions: Has the patient been hearing voices? Thought about killing himself? Any passing patient can hear.

Fulton State’s patient population peaked at 2,476 in 1940 — the same time the Biggs maximum-security unit opened. Later trends toward outpatient treatment and de-institutionalization brought population levels down over the following decades.

Today, the hospital has room to treat 376 patients. More than 1,000 people work to care for patients and the facility. That includes maintenance workers who patch and repair the aging structures ($73 million in repair work has been deferred, pending a new hospital) and teams of registered nurses, licensed practical nurses, direct-care staff, psychiatrists, technicians, caseworkers and social workers.

Food service workers prepare meals on site, administrators keep the office running smoothly, and a security team ensures patient and worker safety.

A new hospital would not lower needed staffing levels, though hospital officials hope upgraded and safer facilities would help address a chronic shortage of registered nurses, who are central to daily treatment.

RNs administer medications and interact with patients in the wards, but high on-the-job injury rates keep turnover and vacancy rates at the hospital stubbornly high. Hospital records from December 2013 estimated the RN vacancy rate at 40 percent, though Martin-Forman said the number decreased after RNs received a raise.

Antique kitchen conditions

The hospital’s dietary center sits a short drive from Biggs. Food has to be loaded on box trucks at every meal; trucking meals to the hospital can make controlling food temperature difficult.

Dietary workers spend summers working in a kitchen without air conditioning. They spend cold winter days cooking in their coats.

The 1930s walk-in fridge —the peeling white paint on the door frame hints at its age — is original to the dietary building and by far the coolest place for a worker to be in the summer.

“We’ve made excellent use of the state’s resources,” Martin-Forman says without a hint of sarcasm.

The hospital’s massive silver oven and giant stand-mixer are relics from the Korean War. They once served a warship; the hospital inherited the appliances when the fighting stopped. Parts for the oven are no longer manufactured, and no one is sure what will happen if it breaks.

In a new facility, the dietary center would be right next to patient quarters, eliminating the need to transport food. The kitchen also would be downsized. The current space is large enough to cook for more than 1,000 patients, though workers now prepare meals for just 350 patients plus 100 inmates at the Callaway County Jail.

Food workers mix salads in massive silver bowls, while above them paint peels from a waterlogged ceiling. The ceiling sits under the floor of an abandoned gym. Martin-Forman’s children once killed time by playing basketball there, but the gym was closed when workers discovered asbestos in the walls and ceiling.

The hospital’s maintenance budget had no room for asbestos removal, so the carcinogen lingers above the food preparation area.

Pools of gray-green water, a product of a leaky roof, sit in some of the kitchen’s fluorescent lights. Workers worry about it, but there’s not much they can do.

“Water and electric don’t really mix, but that’s just what we have to deal with,” says food service manager Alan Sherrell.

Improvements in design

James Hunt, an architect who consults on building psychiatric hospitals and behavioral health facilities from Topeka, Kan., knows what to look for in a state-of-the-art facility.

Since the 1970s, he has designed and consulted on more than 60 hospitals in 30 states. Although he is not involved with the Fulton project, which is in the early design stages, he is familiar with the campus and has worked on other hospitals in Missouri.

“With Fulton, it’s probably more practical to replace it than rehab it,” Hunt said. “It would be more expensive to rehab it at this point.”

Hunt’s latest Design Guide, an industry publication that includes space recommendations and listings of safety products, contains hundreds of recommendations. It says space should strive to look residential, rather than institutional.

For example, let in more light by installing large windows, which Hunt said are a safe option if hospitals install hurricane-grade glass.

“They weren’t designed for our industry, but we’ve been utilizing them pretty heavily to help open up, brighten and allow more daylight into the spaces,” he said.

Although Hunt said medical/surgical hospitals aren’t all that similar to psychiatric hospitals, experts recommend both types of hospitals have 8-foot wide hallways. He said 6 feet is the industry minimum, but 8 feet allows a hospital to comfortably wheel a bed down a corridor. 

In a place like Fulton, without hospital beds, the wider halls give patients and staff more room to maneuver. If a patient attacks a staff member, wider halls also give the staff member more room to break free.

Architects still haven’t found the perfect material to use in psychiatric hospital ceilings, Hunt says, but the latest sound-isolating drywall products keep high, hard ceilings, which can’t be damaged by flailing patients, from bouncing around too much sound.

Right now, patients can easily rip metal bars out of Fulton’s 8-foot ceilings — there’s evidence of that in the hallways — or hide contraband in the ceiling tiles.

“It’s really kind of difficult to keep up with the advancements and products to use,” Hunt said.

Technology and standards may be moving quickly, but Hunt pointed out that psychiatric hospitals’ current standards of being therapeutic, well-lit and welcoming places have been in place for years.

“The words don’t change,” Hunt said. “The pictures do. We’re still trying to do the same things, and I think we’re doing them much better.”

But he noted that a few decades from now, current best practices will probably seem untenable.

“It’s an incremental process,” he said.

Accreditation and safety

Despite its facility limitations, Fulton State is accredited by the Joint Commission on Accreditation of Healthcare Organizations, a national nonprofit that evaluates hospitals on safety and quality of care.

Martin-Forman says that while hospital buildings are old, the treatment methods are not. Psychiatric treatment methods evolve quickly, just as building standards do.

Hospital psychiatrists stay up-to-date and follow national practice guidelines — laid out by the American Psychiatric Association — for assessing and treating psychiatric disorders. In the hospital's three-year accreditation review in 2012, the Joint Commission deemed Fulton’s treatments effective and safe.

Sometimes, however, the hospital’s old design can make modern treatment methods hard to employ. Restraining and secluding irate patients is rarely a best practice today, but the preferred alternative — a manual hold where patient aides stand on either side of an angry patient for as long as it takes to calm him down — can be nearly impossible in Biggs’ narrow hallways, which are scarcely wider than the average man’s wingspan.

“We try to do nationally known treatment in a facility that really doesn’t accommodate that,” said hospital director Russell DeTrempe.

Martin-Forman says her facility has a breaking point, but she’s not sure what that is. Despite its ailing facilities, the hospital has maintained accreditation since 1984. The dietary center is subject to regular inspections, just like any public restaurant. No one is sure how much longer those approvals will last.

To Martin-Forman, this is the year the legislature needs to take action on the hospital. Reports say the hospital could be finished by late 2016 if construction workers break ground next year. 

“We’re at the end of what we can do with what we have,” Martin-Forman said. “We’re putting it together with bubblegum and baling wire.”

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