The conditions described by the veteran nurse sounded more like an overwhelmed clinic in a Third World country or a prison camp hospital from another era, rather than a ward in a well-financed hospital in a major American city in the 21st century.
“I felt like a Nazi prison guard,” said Jason Blalock, who worked at John Peter Smith hospital for 19 years, including a little over a year in its inmate care unit.
He spoke of a place so cramped that if a patient went into distress, nurses might not have been able to get the bed through the obstacle course of small rooms, tight corners, and crowds of law enforcement officers in time to save the person’s life. Raw sewage leaked out of drains so often that staffers covered the drains with duct tape. The showers were filthy. Blood and fecal matter were left in the room of an AIDS patient. A ventilation system was so inadequate that it represented its own health hazard. Patients with communicable diseases were placed alongside other patients because there was no isolation area. And, indeed, the feeling was that the patients in the area – sometimes chained to their beds – were considered beneath notice, that perhaps they didn’t need things like sanitary conditions, functioning equipment, or critical care.
It was a picture that Blalock, whom one former colleague described as heroic, saw every work day in the Inmate Patient Area at Fort Worth’s John Peter Smith hospital. The conditions, he said, were what led him to quit JPS almost a year ago, after months of complaining to superiors to no avail.
One of Blalock’s former co-workers, Julie Ross, who worked at JPS for 16 years, described Blalock as a caring, hardworking, experienced professional, who was eventually pushed out the door by pervasive mismanagement and an impossible work environment.
“He is an excellent nurse. He worked there for almost 20 years,” she said. “To let him leave was the worst thing they could have done. He went way above and beyond.”
In the year since Blalock left, times have changed at JPS. But other former nurses at the county’s public hospital confirm his description of conditions in the Inmate Patient Area, or IPA unit, where county, state, and federal inmates are sent for medical treatment. And while conditions at the unit have improved, administrators agree that other serious problems remain.
David Cecero, the CEO on whose watch the conditions in the prison hospital unit were allowed to deteriorate so far, was ousted by the JPS board last May, albeit with a $775,000 parachute to break his fall from grace. Members of the hospital’s new management team, including new leader Robert Earley, who was made the permanent CEO three weeks ago after serving as the hospital’s interim chief since last May, say the IPA unit was one of their first concerns.
“One of the first areas that we looked into is our IPA unit,” said Earley. “We saw a definite need for change in that area and key needs for changes in other areas as well.”
Earley and Bob Whitman, the hospital’s new chief operating officer, don’t accept all of Blalock’s criticisms as valid. But they are acting on many of them. “Several issues raised by this employee have been addressed over the last year,” Whitman said.
Earley and Whitman said they have replaced the unit’s manager and the hospital’s environmental services company – the folks responsible for keeping the entire hospital clean. Whitman, who previously held the chief operating officer’s job with Harris HEB Hospital in Bedford, said that within the next several months he will have a plan in place for either expanding and renovating the unit, moving it, or closing it entirely and handling inmate patients differently.
Most of the unit’s problems can’t be solved in its current quarters because the space is too small and outmoded. But other fixable problems that former employees brought to light have yet to be resolved – though administrators are working on them. The unit is still crowded with various law enforcement officials, the lack of proper air flow still makes infections a threat (though administrators said that contagious patients are no longer kept in the IPA unit), there is only one shower, and the unit is short-staffed.
The new administrators paint a much brighter picture of the current state of the IPA. They said equipment has been fixed or replaced and the new environmental services company is doing a good job of keeping the unit clean. Earley and Whitman also said they will meet with Tarrant County Sheriff Dee Anderson later this week to discuss the unit in detail.
On the corner of Main and Allen streets in Fort Worth’s hospital district, two very different buildings face each other. One side of Main houses a shimmering new, state-of-the-art medical pavilion; on the other side sits an old weatherworn building with all the architectural charm of a medieval dungeon. A walkway over Main Street connects the two. Inside the old building, a series of turns leads to a thick, bullet-proof door in one of the oldest parts of the structure. Behind it is the IPA.
Inside each of the rooms, or pods as they are called by staff, are four beds, some empty, some occupied by men and women in hospital gowns, chains dangling from their beds. The ceiling is a maze of exposed pipes, and the pods themselves are full of milling security personnel spilled over from the cramped hallway. While JPS was spending nearly $100 million on the shiny new medical pavilion, inmate patients were being treated here, in what former employees called unsafe and unsanitary conditions.
The IPA occupies what was the original JPS emergency room. The area, known as the “old yard” – though it has always been indoors – was closed down in 1991 and used as a storage area. It was reopened in 2006, after JPS officials suggested it as an answer to the sheriff’s longstanding request for a separate and secure inmate area inside the hospital. Before 2006, inmates were cared for among the hospital’s general population, but closely guarded.
In addition to county inmates, the unit also treats state and federal prisoners. The hospital contracts with the University of North Texas Health and Science Center, which contracts in turn with the Federal Bureau of Prisons and other federal agencies to provide hospital care for inmates. When UNTHSC closed its hospital in 2004, officials struck a deal that allows JPS to take care of the prisoners. The IPA unit and prisoner care generated about $5.3 million in revenue for the hospital in 2007.
The hospital is no stranger to controversy concerning prisoner treatment. In recent years, JPS had come under fire for the poor medical care it provided to prisoners at the Tarrant County jail and to prisoners transferred there from the women’s prison hospital at Carswell, which also contracts with the health science center.
Blalock complained that the old yard is too cramped to adequately house the IPA, where one or more guards accompanies each state or federal inmate. He described it as an obstacle course for anyone who had to move a bed to the intensive care unit or somewhere else.
“They are literally putting people in closets,” he said. “They literally emptied out a supply closet and put people inside.”
There are 19 beds in the unit in rooms so small that beds would have to be rearranged to move any of them out of the unit and up to the ICU. However, unit manager Debbie Raborn said such transfers can be done quickly enough, in three minutes or less.
When county prisoners need acute medical care, the sheriff’s deparment is allowed to take them to only three places: the emergency room, the IPA unit, or, in extreme cases, the ICU.
Ironically, the IPA unit was created to avoid a clown car atmosphere, with crowds of guards around the patients. But the close quarters of the IPA and more intensive supervision rules insisted on by other agencies have resulted in that kind of crowding anyway. And the former nurses said that the heavy presence of guards still didn’t ensure that patients were adequately supervised.
“The intent was to have them in an area that is secure and not have an officer for every inmate, because if we had eight or 10 inmates, we have to have eight or 10 officers [elsewhere in the hospital]. If it’s a secured area, then I can have two or three officers guarding that same number,” said Tarrant County Confinement Chief Bob Knowles. The county keeps only three officers in the unit, but federal prisoners rate two guards each, and private companies that run jails for the state also bring their own personnel. Federal protocol also dictates that if prisoners from different agencies are in the same pod, they must all be chained to the beds.
“It’s not all us,” said Knowles. “There are other inmates from other institutions … they put an awful lot of inmates in that same area.”
Blalock doesn’t accept Raborn’s assurances that the IPA patients can be moved fast enough in a crisis. The little extra time it takes to negotiate the obstacle course, he said, could mean the difference between life and death.
Sheriff Anderson said that he is working with the new JPS administrators to find a better solution.
“It’s not the ideal situation, but it’s a big improvement over what we had when I got here, which is absolutely nothing,” he said. “They [prisoners] had to stay in the regular [emergency] room where I felt like the situation was much more dangerous. We’ve taken a big step in the right direction.”
Maria Ramirez, who was also a nurse in the IPA unit for three years, said that the officers who crowded the hallways weren’t always doing their job. She said that on one occasion, a prisoner got up from his bed, walked to another room and made a telephone call, without interference from any guard.
“There was a lack of supervision,” she said. “All of these officers sit in the hallway, and that’s all they would do – just sit there.”
Whitman acknowledged that the lack of space in the IPA unit is a big problem. One option being considered is to expand the IPA into some of the adjacent space being opened up as other units move to the new patient tower. He said he hopes to have that plan developed within the next few months.
Another option is to get rid of the unit entirely and admit inmate patients directly to regular patient floors.
“We’re going back to the very basics on this: Should this unit even exist?” Earley said. “Obviously, there are issues that we need to address. We’re going to look at all potential options. What services do we provide? How do we provide those services? This gives us the opportunity to look at the overall unit, its effectiveness, its efficiency, where you expand, and if you expand. All of those are on the table, as we begin to look at how to best serve.”
Whitman and Earley addressed many of the former nurses’ allegations directly. On others, however, they provided information only on the current situation, without commenting on whether or not conditions were as bad in the past as the nurses had described. In a walkthrough, this reporter was not allowed to speak to inmates in the IPA due to privacy laws or to enter patient rooms to look at conditions and to see whether equipment was working.
So in many cases, the only direct descriptions of how bad things are or were in the unit come from the nurses. On almost every particular, they agree.
The three former employees all believe that the lack of isolation rooms – for patients with infectious diseases – created a risk of exposing the staff and other patients to communicable diseases.
“We stuck tuberculosis patients down there, and we didn’t have any isolation rooms,” Ramirez said. “So we just put a mask on them, and they had to just sit there exposed to us and others.”
Blalock also said that air flow is a problem in the unit. He said that the unit didn’t have laminar flow – a ventilation system that cuts down on the spread of contagious diseases.
Whitman acknowledged that air flow is still a concern and will be addressed. But now, he said, “Those patients that are contagious aren’t treated there [in the IPA],” he said. “Air flow down in the IPA unit is another concern, and that would be something else we look at in terms of future renovation.”
Blalock said that care in the unit is often “bumped” or delayed, and the staff often ignores patients. Both he and Ramirez believe that the IPA often got the worst staffers: undertrained or inexperienced nurses, people who had screwed up elsewhere or whom the hospital wanted to punish.
Blalock said the hospital viewed the IPA unit as a place for nurses to gain experience on patients who mattered less. One nurse there had been fired from the Tarrant County jail, he said. Ramirez said another nurse stole medications and came to work stoned. That nurse, she said, was transferred to another unit but not fired.
Another former nurse at the IPA unit, who didn’t want to be named for fear of retribution, said that managers transferred nurses to the IPA unit to force them out. “When JPS can’t come up with a reason to fire you, when they can’t generate something that is legitimate, they put you in a place that’s nasty or difficult to work in,” that nurse said. “The IPA is perfect for that.”
According to all of the former IPA nurses interviewed, there was no central monitoring system for patients, so if a patient’s heart stopped or stopped breathing, there would have been no way to tell unless someone was in the room. The nurses also claim that the monitors were hand-me-downs from other areas of the hospital and didn’t always work.
Whitman said the monitors in the IPA are all now functioning, though he did not respond to questions about whether that had been the case in the past.
According to Blalock, the oxygen and suction system – machines attached to the walls to aid patients in breathing – were cut off in one room after a nurse noticed a giant blue flame shooting out of the wall. He said that one room in the unit functioned on haphazard battery-operated oxygen units for over a year.
Raborn denied that the flame incident occurred. She could not show the Weekly reporter that all of the systems were functional, because that would have meant going into occupied rooms.
The former nurses support Blalock’s claim. Ramirez said that the nurses had to jury-rig a system to get oxygen to their patients. “There was no suction and no oxygen in the first two pods,” the nurse said. “We were really afraid that something might happen. We would have to hook up long tubing to portable tanks. They ended up bringing us a portable oxygen canister – that went on for years.”
Whitman said that all of the beds now have oxygen and suction, and telemetry monitors are provided to anyone who needs them.
Blalock and Ramirez both described how raw sewage would well up from the drains when it rained heavily. Blalock complained that soiled linens were stored in the hallway rather than being safely stored in a utility room. He said that the biohazard storage bins – where hazardous material is disposed of – were never cleaned or emptied. There was no access to wheelchairs for patients, he said, and heart monitoring was inadequate. The shower was never cleaned, and patients were seldom bathed, the nurse said. He said that more than once, he himself cleaned blood and fecal matter off the floors and changed the linens, a job usually reserved for the housekeeping staff.
Ross said that it was a constant fight to get housekeeping to come clean the IPA unit, and when they did, they did a poor job.
“The beds were filthy. The linens made me sick,” said Ross. “They had dressings and electrodes stuck to them [from earlier patients] – they’d come back from the laundry like that. They were torn, they were stained, the blankets that we covered [patients] in were so thin. There was frequently blood left on the side railings of the beds or underneath the beds where it would splatter.
“We could not get [housekeeping] to come,” she continued. “It was just a fight every day with environmental services.”
The nurse who had asked not to be named said that the biohazardous materials were once left in the unit for such a long time that, when housekeeping finally picked it up, the bag was teeming with maggots.
Earley said that the hygiene issues at the whole hospital have been addressed. Over the years, the hospital gained a reputation for being dirty, so the new CEO brought in a new environmental services company and said he’s seen a marked difference already.
“We brought in a new crew, and we’re holding them accountable and working very diligently with them to make sure that things are cleaned up. That’s an area that we need to be certain that IPA and other [units] have under control,” he said.
Whitman said that housekeeping is available at all times for the unit and the rest of the hospital. Every time he’s visited the IPA unit, he said, a member of housekeeping has been there.
Blalock cited an example of one female patient who was in an advanced stage of AIDS and suffered from tuberculosis, whom the housekeeping staff waited hours to clean up after. That same woman, Blalock said, wasn’t allowed to go to ICU. “They wouldn’t let her go until she … was just about to die,” he said. “The doctors said ‘Has she stopped breathing yet?’ They have to be dead to get to ICU.”
Both Whitman and Earley vehemently deny the charge that a JPS doctor would allow an inmate to come close to death before taking the patient to ICU.
“I would be shocked,” he said. “That statement is just not true.”
Earley also noted that if a patient stops breathing, law enforcement officers would clear out of the way quickly to allow doctors and nurses to deal with the emergency. “I will tell you when a patient ‘codes,’ it’s a different circumstance,” he said. “Space is going to clear quickly.”
Ross said that the shower was never cleaned between uses, and there were often electrodes left on the floor from patients who had communicable diseases. Ramirez added that the shower door leaked, so inmates had to stuff towels under it to keep water from running down the hall.
And according to Ross, the staff could hear rats scurrying about in the ceiling. One time, she said, a rat died there and stank up the unit for several days before someone came to take care of it.
Ramirez believes that the unit has been neglected because its patients are inmates, without power to choose another hospital and without influence to get their complaints heard. The unit is also closed to outsiders and out of view. Ramirez said that she was told by the house supervisor that, unless patients were dying or in labor, they could not be transferred to another part of the hospital.
“They had to stay in that unit,” she said. “These patients were stuck with other contagious patients and didn’t have a choice. If I was a patient, and I saw those conditions, I’d be out of there. They didn’t have that choice.”
Whitman denied that the hospital makes one type of patient a priority over another. “We attempt in every way possible not to differentiate between levels of patient care,” he said. “Those inmates deserve every bit of the care that we provide others.”
All the nurses said that they took their problems to management and were told for years that, whatever their complaints, management was always “working on it.”
Ross and a group of nurses wrote a letter to Earley when he was first appointed interim CEO last year, and she also e-mailed him separately. Ross said Earley told her he was anxious to speak to her, but that she couldn’t get his secretary to call her back to make an appointment.
Earley said that he and Whitman are trying to change the culture at JPS, and they will welcome criticism and compliments alike – a far cry from the situation under Cecero.
“I’m trying to communicate to the administration that every criticism, every platitude or compliment is given its due process,” he said. “I don’t discredit any comment that anyone would make, whether they are a former employee or a current employee.”
Some of the criticisms levied by Blalock have gained some traction among administrators and managers. Whitman has taken a very hands-on approach to the problems at the IPA unit early on in his time at JPS.
“We’re talking with the nursing staff down there; we’re talking with the new manager that we’ve just elevated to have responsibility for that unit and with the sheriff’s department,” said Whitman. “We are seeking input.”
Raborn provided the Weekly with several letters of appreciation from former patients of the old yard. Due to HIPAA issues, the names of the patients were blacked out. One read simply “I really appreciate [your] kind, compassionate, and caring healthcare.” Another patient wrote that he felt that in leaving the unit he was “leaving a family behind.” A third complimentary letter was addressed to Earley as CEO, showing that it was written well after Blalock’s time at the unit.
Earley, who was the senior vice president at JPS before stepping into his new role, acknowledged that JPS has a long way to go. But, he said, as an organization it has already taken its first step.
“We have some problems, and part of what makes an organization better is admitting your problems,” he said.
“This is a large place, and it takes some time to make those changes,” he continued. “It takes an incredible level of diligence to fix what is wrong and enhance what is right.”
Time hasn’t washed away the bitter stain of Blalock’s memories of the IPA or removed the danger to his medical career from being labeled a troublemaker. But he hopes that something positive will come of his whistle-blowing. He and many others are waiting to see how soon the promises of the new administration will translate into real change.
“It’s a big hill to climb,” he said.
Earley said that change to the hospital as a whole and the IPA unit in particular will not come with a bang and a puff of smoke. He is instead opting for the slow and steady approach.
“I compare it to a diet,” he said. “I’m not interested in losing 40 pounds in one month – I am interested in losing two pounds a week. It’s going to be methodical and pragmatic. Things will not happen overnight, but when they do happen, hopefully the changes will be here to stay.”
Tarrant County commissioners, who appoint members of the hospital system board and who eventually applied the pressure that brought about changes at JPS, are still carefully watching what happens there.
Commissioner Roy C. Brooks said that he believes the new administrators are doing everything necessary to fix the IPA unit, but it will take time.
“We need to give them time to get their program in place before we start throwing darts at them,” he said. “They’ve started fixing the problems, and I’m sure they are committed to seeing it through.”
Brooks said that he’s never seen the IPA unit, and this is the first he’s heard of any problems with it. But he said he will be keeping a close eye on its progress.
“I will personally get myself up to speed on the issue and make my own determination whether or not it is serving the patients and the mission of the hospital.”
You can reach Eric Griffey at eric.griffey@fwweekly.com.
