Hawaii State Hospital Report

PART I.
INTRODUCTION HAWAII STATE HOSPITAL

A. PURPOSE AND ORGANIZATION OF THE HAWAII STATE HOSPITAL

The Hawai i St at e Hospi t al ( Hospi t al ) i s t he onl y publ i cl y
f unded psychi at r i c hospi t al i n t he St at e t hat pr ovi des
speci al i zed i npat i ent psychi at r i c ser vi ces t o adul t s 24- hour s a
day, seven days a week. The Hospi t al i s l i censed by t he
Depar t ment of Heal t h t hr ough t he Of f i ce of Heal t h Car e Assur ance
and i s accr edi t ed by The J oi nt Commi ssi on.

1. Mission and Purpose

The Di r ect or of Heal t h i s aut hor i zed under st at ut e
1
t o
oper at e a secur e psychi at r i c r ehabi l i t at i on pr ogr amf or
i ndi vi dual s who r equi r e i nt ensi ve t her apeut i c t r eat ment and
r ehabi l i t at i on i n a secur e set t i ng. The mi ssi on of t he Hospi t al
i s " t o pr ovi de saf e, i nt egr at ed, evi dence- based psychi at r i c
assessment , t r eat ment and r ehabi l i t at i on t o i ndi vi dual s
suf f er i ng f r ombr ai n, medi cal and behavi or al di sor der s who ar e
pr i mar i l y cour t or der ed t o Hawai i St at e Hospi t al . " The
Hospi t al ' s mi ssi on i s car r i ed out by a st af f of over 600
i ndi vi dual s empl oyed by t he St at e and addi t i onal st af f t hat ar e
cont r act ed f or wi t h t empor ar y empl oyee ser vi ce agenci es t o
pr ovi de di r ect and i ndi r ect psychi at r i c i npat i ent ser vi ces f or
t hose cases di agnosed as ser i ousl y ment al l y i l l , i ncl udi ng t hose
wi t h a co- occur r i ng di agnosi s f or whompsychi at r i c i npat i ent
ser vi ces i s a medi cal necessi t y, and f or t hose cases r ef er r ed or
commi t t ed pur suant t o ci vi l and penal st at ut es who ot her wi se
cannot be di ver t ed i nt o communi t y- based pr ogr ams and ser vi ces.

The Hospi t al of f er s ser vi ces t o assess, t r eat , and
r ehabi l i t at e t he pat i ent s.
2
Pat i ent s at t he Hospi t al r ecei ve
psychi at r i c and non- psychi at r i c t r eat ment t o addr ess var i ous
medi cal condi t i ons, such as di abet es and hepat i t i s. Pat i ent s
ar e al so pr ovi ded psychol ogi cal ser vi ces, i ncl udi ng i ndi vi dual
and gr oup t her apy, as wel l as cogni t i ve or behavi or al and
educat i onal i nt er vent i on. Fi nal l y, pat i ent s r ecei ve soci al
ser vi ces t o assi st t hemi n r esol vi ng l egal i ssues; obt ai ni ng
f ood, cl ot hi ng, and shel t er upon di schar ge f r omt he Hospi t al ;
1
See, 334- 2. 5( b) , Hawai i Revi sed St at ut es.
2
See, Depar t ment of Heal t h, Report to the Twenty-Fourth Legislature Pursuant
to S.C.R. No. 117, S.D. 1, H.D. 1 Regarding the Final Report of the Task
Force Convened to Evaluate the Recommended Possible Procedural, Statutory,
and Public Policy Changes to Minimize the Census at Hawaii State Hospital and
Promote Community-Based Health Services for Forensic Patients, Appendi x 4:
Or i ent at i on t o t he Hawai i St at e Hospi t al ( December 2007) .
2014- 0897 HSH Fi nal Repor t . docx Page 1 of 76

and engagi ng i n communi t y r ei nt egr at i on, i ncl udi ng j ob t r ai ni ng,
educat i on, and mai nt ai ni ng meani ngf ul i nt er per sonal
r el at i onshi ps.

2. Organization

The Hospi t al i s admi ni st er ed by t he Depar t ment of Heal t h
wi t h over si ght pr ovi ded by t he Depar t ment ' s Adul t Ment al Heal t h
Di vi si on under t he Behavi or al Heal t h Admi ni st r at i on. The Deput y
Di r ect or of Behavi or al Heal t h and t he Adul t Ment al Heal t h
Admi ni st r at or del egat e t hei r aut hor i t y t o t he Hawai i St at e
Hospi t al Admi ni st r at or t o pl an, di r ect , and over see t he
or gani zat i onal st r uct ur e and oper at i ons of t he Hospi t al . As
such, t he Hospi t al Admi ni st r at or wor ks cl osel y, cooper at i vel y,
and col l abor at i vel y wi t h t he Adul t Ment al Heal t h Admi ni st r at or
and t he admi ni st r at i ve st af f of t he Adul t Ment al Heal t h Di vi si on
i n i dent i f yi ng t r eat ment and r ehabi l i t at i on pr ogr ammi ng ser vi ces
and act i vi t i es needs; pr obl emsol vi ng; devel opi ng pol i cy;
i mpl ement i ng and coor di nat i ng ef f ect i ve cor r ect i ve act i on; and
r edi r ect i ng and i nt egr at i ng publ i c and pr i vat e pr ogr ams and
ser vi ces. The f ol l owi ng or gani zat i on char t di spl ays a segment
of t he or gani zat i on hi er ar chy wi t hi n t he Depar t ment of Heal t h.

Figure 1.1
Abbreviated Department of Health Organization Chart

Sour ce: Gui de t o St at e Gover nment i n Hawai i
3

3
Legi sl at i ve Ref er ence Bur eau, Guide to Government in Hawaii ( 14
t h
ed. , LRB
2013) .
Director of
Health
General
Administration
Behavioral
Health
Administration
Alcohol and Drug
Abuse Division
Child and
Adolescent
Mental Health
Division
Adult Mental
Health Division
Hawaii State
Hospital
Community
Mental Health
Centers
Courts and
Corrections
Branch
Developmental
Disabilities
Division
Environmental
Health
Administration
Health Resources
Administration

The Hospi t al i s or gani zed i nt o f our sect i ons, i ncl udi ng t he
Admi ni st r at i ve and Suppor t Ser vi ces, Af f i l i at ed Pr ogr ams,
Cl i ni cal Ser vi ces, and Qual i t y Management Ser vi ces Sect i ons,
wi t h t he Hospi t al Admi ni st r at or ser vi ng as t he head of t he
Hawai i St at e Hospi t al Br anch. An Associ at e Admi ni st r at or who
r epor t s t o t he Hospi t al Admi ni st r at or heads each sect i on and
each sect i on i s f ur t her di vi ded i nt o and suppor t ed by var i ous
uni t s and of f i ces. Fi gur e 1. 2 i l l ust r at es t he f our sect i ons of
t he Hospi t al and t he var i ous uni t s and of f i ces of t he Cl i ni cal
Ser vi ces Sect i on.

Figure 1.2
Hawaii State Hospital Organization Chart

Sour ce: Depar t ment of Heal t h
4

I n t er ms of i npat i ent ser vi ces, t he Hospi t al oper at es f i ve
r ehabi l i t at i on i npat i ent uni t s
5
t hat gener al l y ser ve t he l onger -
t er mneeds of pat i ent s and t wo acut e uni t s
6
wi t h one of t hese
uni t s al so ser vi ng as t he admi ssi ons uni t f or t he ent i r e
hospi t al . Fur t her mor e, t he Hospi t al campus al so i ncl udes a
St at e Oper at ed Speci al i zed Resi dent i al Pr ogr am( SOSRP) , whi ch
ser ves as a communi t y r esi dent i al r esour ce f or out pat i ent car e.
Most of t he r esi dent s of t hi s pr ogr amar e pat i ent s who ar e
di schar ged f r omt he Hospi t al and on condi t i onal r el ease.
4
Depar t ment of Heal t h Posi t i on Or gani zat i on Char t , Funct i onal Char t Nos. 1
and 8 dat ed Apr i l 16, 2014 ( MAF_043014_05_B0001 and B0008) .
5
The f i ve r ehabi l i t at i on uni t s ar e Uni t s E, I , S, T, and U.
6
The t wo acut e uni t s ar e Uni t s F and H. Uni t H al so ser ves as t he admi ssi ons
uni t .
Hawaii State
Hospital Branch
Administrative &
Support Services
Section
Affiliated
Programs Section
Clinical Services
Section
Clinical
Psychology
Clinical Safety
Forensic Services Medical Services
Nursing
Psychiatric
Services
Rehabilitation
Program
Social Work
Services
Quality
Management
Services Section

3. Budget

The Hospi t al ' s oper at i ng budget i s pr edomi nat el y f i nanced
by gener al f unds.
7
I n FY2014, t he appr opr i at ed budget was
$52, 895, 657.
8
Accor di ng t o t he Depar t ment of Heal t h, t wo- t hi r ds
( $35, 343, 719) of t hat appr opr i at ed sum
9
was expended f or
per sonnel cost s. The per sonnel cost s t ake a maj or i t y of t he
Hospi t al ' s oper at i ng budget because t he budget i s based on a
census of 168 pat i ent s, whi ch i s about 25- 30 pat i ent s l ess t han
t he act ual dai l y census. A census t hat exceeds t he budget ed
number of pat i ent s r equi r es t he r egul ar use of over t i me or
adj ust ment s t o i ncr ease st af f i ng.

I n addi t i on t o t he 168 budget ed beds, t he Hospi t al has a
cont r act wi t h Kahi Mohal a Behavi or al Heal t h,
10
a pr i vat e
psychi at r i c hospi t al owned by t he not - f or - pr of i t cor por at i on,
Sut t er Heal t h, f or 40 suppl ement al adul t i npat i ent psychi at r i c
beds or over f l ow beds. Wi t h t hese 40 over f l ow beds added t o t he
aver age dai l y pat i ent census, t he Hospi t al r out i nel y oper at es at
appr oxi mat el y 70 pat i ent s, or 42%, over t he budget ed pat i ent
census. Fur t her mor e, t he usage of t he over f l ow beds at Kahi
Mohal a subst ant i al l y i ncr eased dur i ng FY2012.
11
The capaci t y of
over f l ow beds i ncr eased f r om16 beds i n Febr uar y 2012 t o 32 beds
i n J une 2012 and t o 40 beds i n J ul y 2012.
12
Accor di ngl y, t her e
i s a hi gh l i kel i hood t hat t he number of cont r act ed over f l ow beds
may i ncr ease i n t he f ut ur e, t hus i ncr easi ng t he Hospi t al ' s
f i nanci al needs.

7
An anal ysi s of t he Hospi t al ' s oper at i ng budget i ndi cat es an unsubst ant i al
i nf usi on of t r ust f und moneys compr i sed of donat i ons or gi f t s. No awar ds of
f eder al f unds wer e r epor t ed f or FY2014 or r equest ed f or FY2015.
8
See, Gener al Appr opr i at i ons Act of 2013 ( Act 134, Sessi on Laws of Hawai i
2013) .
9
See, Power Poi nt mat er i al s submi t t ed by t he Depar t ment of Heal t h t o t he
Senat e Commi t t ees on Heal t h and J udi ci ar y and Labor f or t he I nf or mat i onal
Br i ef i ng on J anuar y 7, 2014 ( LR_01_0033- 0061) .
10
Depar t ment of Heal t h, Report to the Twenty-Seventh Legislature Pursuant to
the Hawaii Revised Statutes 334-16, Requiring the Department of Health to
Submit an Annual Report on Forensic Patient Data Specific to Hawaii State
Hospital ( December 2013) ( LR_01_0001- 0027) .
11
12

Figure 1.3
Hawaii State Hospital Operating Budget Appropriations, FY2011-
2015

Program ID: HTH430 Adult Mental Health Inpatient
FY2011 FY2012 FY2013 FY2014 FY2015
Positions 615.00 615.00 615.00 615.00 615.00
General Funds $50,667,161 $52,895,657 $51,617,843 $52,895,657 $57,999,657

Sour ce: Gener al and suppl ement al appr opr i at i ons Act s, Sessi on Laws of Hawai i
2010 t o 2014
13

B. PATIENTS AT THE HAWAII STATE HOSPITAL

The pat i ent census at t he Hospi t al t ypi cal l y consi st s of
al most 200 i ndi vi dual s. Accor di ng t o t he Depar t ment of Heal t h,
t he spect r umof pat i ent s admi t t ed t o t he Hospi t al has changed
over t he year s. Vi r t ual l y al l admi ssi ons t o t he Hospi t al ar e
f or ensi c ment al heal t h admi ssi ons i n whi ch i ndi vi dual s ar e
commi t t ed t o t he cust ody of t he Depar t ment of Heal t h by st at e
cour t s and sent t o t he Hospi t al .

1. Spectrum of Patients

Many of t he i ndi vi dual s hospi t al i zed at t he Hospi t al do not
r equi r e i npat i ent psychi at r i c ser vi ces, do not have a bona f i de
ment al i l l ness, or r emai n i n t he Hospi t al much l onger t han i s
cl i ni cal l y necessar y. I ndi vi dual s ar e commi t t ed t o t he Hospi t al
due t o pr obl ems, i ncl udi ng dement i a, acqui r ed and t r aumat i c
br ai n i nj ur i es, devel opment al del ays, subst ance abuse, and
gener al medi cal condi t i ons, pr i mar i l y because t he cour t cannot
r equi r e or i dent i f y a mor e appr opr i at e pl acement . Fur t her mor e,
most pat i ent s have co- occur r i ng subst ance abuse pr obl ems.
Accor di ng t o t he Special Action Team Report on the
Revitalization of the Adult Mental Health System and Effective
Management of the Hawaii State Hospital Census, pat i ent s of t he
Hospi t al exper i ence si gni f i cant i nequi t i es compar ed t o peopl e
wi t hout ment al i l l ness or not commi t t ed t o t he Depar t ment of
Heal t h i n gai ni ng access t o l ong- t er mcar e beds, medi cal l y
necessar y physi cal heal t h car e, and housi ng.

13
See, Act 180, Sessi on Laws of Hawai i 2010, f or FY2011; Act 164, Sessi on
Laws of Hawai i 2011, f or FY2012; Act 106, Sessi on Laws of Hawai i 2012, f or FY
2013; Act 134, Sessi on Laws of Hawai i 2013, f or FY 2014; and Act 122, Sessi on
Laws of Hawai i 2014, f or FY2015.

Figure 1.4
Spectrum of Patients by Primary Diagnosis on December 01, 2013

Primary Diagnosis Number
Schizophrenia and Related Diagnoses 124
Bipolar, Major Depression, and Other Mood
Disorders 22
Substance Use Disorders 10
Other (both psychiatric and non-psychiatric
diagnoses) 38
No Diagnosis 4
TOTAL 198

14

2. Admissions from the Court System

The i npat i ent psychi at r i c ser vi ces at t he Hospi t al ar e
pr ovi ded t o adul t s who ar e vol unt ar i l y or i nvol unt ar i l y
hospi t al i zed, commi t t ed t o t he cust ody of t he Di r ect or of Heal t h
under chapt er 704, Hawai i Revi sed St at ut es ( HRS) , or
appr opr i at el y hospi t al i zed under chapt er 704 or 706, HRS.
However , t he Depar t ment r epor t ed t hat vi r t ual l y al l of i t s
admi ssi ons ar e cour t or der ed.

The admi ssi on of f or ensi c ment al heal t h pat i ent s t o t he
Hospi t al has i ncr eased pr i mar i l y due t o t he t r ansf er t i mef r ames
mandat ed under t he Cl ar k per manent i nj unct i on.
15
Thi s per manent
i nj unct i on appl i es t o al l st at e cour t or der s t o t r ansf er per sons
t o t he cust ody of t he Di r ect or of Heal t h wi t hi n 72 hour s of an
or der decl ar i ng Acqui t t al on t he Gr ound of Physi cal or Ment al
Di sease, Di sor der , or Def ect Excl udi ng Responsi bi l i t y ( " Not
Gui l t y by Reason of I nsani t y" ) ( 704- 411( 1) ( a) , HRS) ; Unf i t t o
Pr oceed ( 704- 406, HRS) ; or I nvol unt ar y Ci vi l Commi t ment
( 706- 607, HRS) , and wi t hi n 48 hour s of an or der decl ar i ng
Revocat i on of Condi t i onal Rel ease ( 704- 413( 4) , HRS) . Fi gur e
1. 5 i l l ust r at es t he number of pat i ent s admi t t ed t o t he Hospi t al
dur i ng FY2013 by t he l egal st at us of t he admi ssi on.

14
15
See, Cl ar k v. St at e of Hawai i , St i pul at i on f or Amended Per manent
I nj unct i on, No. CV 99- 00885 DAE/ BMK ( 2003) ( LR_07_0033- 0040) .

Figure 1.5
Spectrum of Patients by Type of Admission for FY2013

Type of Admission
No. of
Patients
% of Total
Admission
704-411(1)(a), HRS
Acquittal on the Ground of Physical or Mental Disease,
Disorder, or Defect Excluding Responsibility ("Not Guilty by
Reason of Insanity") 23 7%
704-413(4), HRS
Revocation of Conditional Release 0 0%
704-413(1), HRS
72 Hour Hold on a Motion to Revoke Conditional Release 112 33%
704-404, HRS
Evaluation of Fitness to Proceed 54 16%
704-406, HRS
Unfit to Proceed 137 40%
704-406(3) and (4) and 706-607, HRS
Involuntary Civil Commitment 13 4%
Voluntary Commitments 0 0%

16

As a r esul t of t he Cl ar k per manent i nj unct i on and t he
i ncr ease i n t he admi ssi on of f or ensi c ment al heal t h pat i ent s,
17

t he Hospi t al ' s abi l i t y t o admi t i ndi vi dual s subj ect t o
i nvol unt ar y ci vi l commi t ment by t he Fami l y Cour t s i s hamper ed,
and t he vol unt ar y commi t ment of per sons who may r equi r e
l onger - t er mpsychi at r i c r ehabi l i t at i on i s ef f ect i vel y pr ecl uded.
Thus, f or ensi c admi ssi ons have account ed f or vi r t ual l y al l of
i t s admi ssi ons, wi t h t he Depar t ment of Heal t h r epor t i ng t hat i t s
cur r ent pat i ent census i s compr i sed sol el y of f or ensi c ment al
heal t h pat i ent s.

Accor di ng t o t he Depar t ment of Heal t h, t he number of
admi t t ed f or ensi c ment al heal t h pat i ent s who ar e char ged wi t h a
mi sdemeanor of f ense
18
and pat i ent s who ar e char ged wi t h a f el ony
16
17
Promote Community-Based Health Services for Forensic Patients ( December
2007) .
18
See, 706- 640 and 706- 663, HRS.

of f ense
19
ar e appr oxi mat el y equal .
20
I n addi t i on, most of t he
pat i ent s at t he Hospi t al have not been f ound gui l t y of any
char ges, and 40%of t he cr i mi nal of f ense char ges do not i nvol ve
of f enses agai nst anot her per son. Fur t her mor e, pat i ent s wi t h
mor e ser i ous char ges gener al l y have l onger l engt hs of st ay at
t he Hospi t al , wi t h a smal l number of pat i ent s ( al l mal e) who ar e
char ged wi t h cl ass A f el oni es
21
wi t h l engt hs of st ay l onger t han
20 year s.

C. EMPLOYEES OF THE HAWAII STATE HOSPITAL

The Hospi t al empl oys over 600 empl oyees who pr ovi de di r ect
psychi at r i c i npat i ent ser vi ces, such as psychi at r i st s, medi cal
physi ci ans, r egi st er ed nur ses, psychi at r i c t echni ci ans,
par a- medi cal assi st ant s, psychol ogi st s, l abor at or y t echni ci ans,
occupat i onal t her api st s, r ecr eat i onal t her api st s, soci al
wor ker s, and di et i ci ans. The Hospi t al i s suppor t ed by st af f t o
per f or madmi ni st r at i ve dut i es, such as human r esour ces,
management i nf or mat i on syst ems, t el ecommuni cat i on ser vi ces,
secur i t y, f i scal management and qual i t y management ; and a st af f
f or pl ant and f aci l i t i es management .

As st at e empl oyees, Hospi t al st af f ar e ci vi l ser vant s
unl ess speci f i cal l y exempt and par t of col l ect i ve bar gai ni ng
unl ess speci f i cal l y excl uded. Empl oyees who ar e par t of
col l ect i ve bar gai ni ng ar e r epr esent ed by t he Hawai i Gover nment
Empl oyees Associ at i on, AFSCME Local 152, AFL- CI O ( HGEA) or
Uni t ed Publ i c Wor ker s, AFSCME Local 646, AFL- CI O ( UPW) and have
cer t ai n empl oyee r i ght s and benef i t s negot i at ed under t hei r
r espect i ve col l ect i ve bar gai ni ng agr eement s.

The aver age dai l y pat i ent census f or cal endar year 2013 at
t he Hospi t al was 192 pat i ent s,
22
whi ch i s 24 pat i ent s over t he
Hospi t al ' s budget ed census of 168 pat i ent s. As a r esul t , i n
addi t i on t o t he Hospi t al ' s payr ol l of over 600 empl oyees, t he
Hospi t al cont r act s f or r egi st er ed nur ses, psychi at r i c
t echni ci ans, and par a- medi cal t echni ci ans t o pr ovi de appr opr i at e
st af f i ng l evel s f or t he car e f or i t s over - census pat i ent
popul at i on.
19
See, 706- 640, 706- 660, and 706- 659, HRS.
20
21
The vi ol at i on of a cl ass A f el ony i s puni shabl e by an i ndet er mi nat e of
i mpr i sonment 20 year s and a f i ne not exceedi ng $50, 000. See, 706- 640 and
706- 659.
22

PART II.
SENATE SPECIAL INVESTIGATIVE COMMITTEE
ON THE HAWAII STATE HOSPITAL

A. IMPETUS OF SPECIAL INVESTIGATIVE COMMITTEE

The Hawai i St at e Hospi t al has gar ner ed r egr et t abl e
at t ent i on on t he f eder al and st at e l evel s over t he past 20 year s
r egar di ng t he condi t i ons, census, and qual i t y of car e at t he
Hospi t al . Despi t e numer ous ef f or t s, t he Hospi t al cont i nues t o
be a subj ect of concer n.

1. Federal Intervention

I n 1991, t he Uni t ed St at es Depar t ment of J ust i ce ( DOJ )
f i l ed sui t agai nst t he St at e of Hawai i f or vi ol at i ons of t he
const i t ut i onal r i ght s of pat i ent s of t he Hospi t al pur suant t o
t he f eder al Ci vi l Ri ght s of I nst i t ut i onal i zed Per sons Act ( 42
U. S. C. 1997 et seq. ) . I t was r epor t ed t hat car e f or pat i ent s
was subst andar d, t he bui l di ngs l eaked, some pat i ent s wer e
admi ni st er ed t oo much medi cat i on, pat i ent s wer e l ef t unat t ended
l yi ng on concr et e f l oor s or wer e r out i nel y r est r ai ned, st af f i ng
was i nadequat e, and condi t i ons wer e unsaf e and unsani t ar y.
23

That same year , t he St at e and t he Uni t ed St at es t hr ough t he DOJ
ent er ed i nt o a set t l ement agr eement
24
t o cor r ect t he def i ci enci es
at t he Hospi t al , whi ch became an or der of t he f eder al cour t .

I n 1995, t he cour t f ound t he St at e i n cont empt of cour t f or
f ai l ur e t o achi eve i mpor t ant r equi r ement s of t he cour t or der .
As a r esul t , t he DOJ and St at e negot i at ed a st i pul at i on and
det ai l ed r emedi al pl an
25
desi gned t o addr ess t he vi ol at i ons and
pr obl ems at t he Hospi t al .

I n 1999, t he Feder al Di st r i ct Cour t f ound t hat t he Hospi t al
was st i l l gr ossl y out of compl i ance
26
wi t h si gni f i cant
r equi r ement s of i t s or der s, most not abl y t he r equi r ement s t hat
t he St at e pr ovi de adequat e t r eat ment and t r eat ment pl anni ng f or
al l pat i ent s at t he Hospi t al . Despi t e t he cour t - or der ed
f or mat i on of a compl i ance commi t t ee t o i dent i f y and i mpl ement
23
Ken Kobayashi , Feds to end oversight at state mental hospital, Honol ul u
Adver t i ser ( November 13, 2004) .
24
Uni t ed St at es v. St at e of Hawai i , et al . , Set t l ement Agr eement and Or der ,
Ci vi l No. 91- 00137 DAE ( 1991) ( LR_07_0046- 0083) .
25
Uni t ed St at es v. St at e of Hawai i , et al . , St i pul at i on and Or der t o Remedy
Def endant s' Cont empt of Set t l ement Agr eement , Ci vi l No. 91- 00137 DAE ( 1995)
( LR_07_0096- 0153) .
26
Uni t ed St at es v. St at e of Hawai i , et al . , Or der Est abl i shi ng Compl i ance
Commi t t ee, Repor t i ng Schedul e, and Set t i ng St at us Conf er ence, Ci vi l No.
91- 00137 DAE ( 1999) ( LR_07_0219- 0221) .

sol ut i ons t o al l out st andi ng i ssues of mat er i al si gni f i cance f or
compl i ance, t he St at e was unabl e t o t ake adequat e cor r ect i ve
act i on i n accor dance wi t h t he pl ans of t he compl i ance commi t t ee.

Subsequent l y, t he cour t appoi nt ed a speci al moni t or t o
over see compl i ance i n 2000. The speci al moni t or ' s r epor t f i l ed
i n 2001 ci t ed t hat many oper at i onal pr obl ems cont i nued at t he
Hospi t al , i ncl udi ng over cr owdi ng and st af f i ng, saf et y, and
mor al e pr obl ems.
27
Fur t her mor e, HGEA f i l ed a gr i evance f or t he
nur ses about t he condi t i ons. As a r esul t , t he cour t appoi nt ed a
speci al mast er i n 2001 t o over see st at e compl i ance wi t h f eder al
l aws at t he Hospi t al .

I n 2004, t he speci al mast er r ecommended di smi ssi ng t he
f eder al ci vi l r i ght s l awsui t agai nst t he Hospi t al and
t er mi nat i ng f eder al cour t over si ght of t he Hospi t al . The
speci al mast er r epor t ed t hat st at e of f i ci al s made " subst ant i al
pr ogr ess and dr amat i c change" at t he Hospi t al , wi t h pat i ent s now
bei ng t r eat ed i n " a di f f er ent and successf ul way. "
28
Despi t e t he
r ecommendat i on t o t er mi nat e t he f eder al cour t over si ght of t he
Hospi t al , t he speci al mast er r ecommended t hat t he f eder al cour t
cont i nue t o moni t or unt i l J une 30, 2006, t he St at e' s ef f or t s i n
i mpl ement i ng a communi t y pl an f or peopl e wi t h ser i ous ment al
i l l nesses who ar e f or mer pat i ent s or who wi l l be r el eased f r om
t he Hospi t al . On November 30, 2006, 15 year s af t er t he l awsui t
was f i l ed, t he f eder al case was di smi ssed wi t h pr ej udi ce.
29

2. Executive Intervention

Af t er t he f eder al cour t over si ght , t he Hospi t al cont i nued
t o be an ar ea of concer n, especi al l y wi t h r egar d t o pat i ent
census and communi t y- based ser vi ces f or f or ensi c ment al heal t h
pat i ent s. As a r esul t , t he Gover nor ' s Admi ni st r at i on engaged i n
ef f or t s t o i dent i f y pr obl ems at t he Hospi t al , r ecommend
sol ut i ons t o addr ess t hese pr obl ems, and pr event t he Hospi t al
f r omf al l i ng under f eder al over si ght agai n.

a. Governor's Task Force Pursuant to S.C.R. No. 117

Dur i ng t he Regul ar Sessi on of 2006, t he Legi sl at ur e passed
S. C. R. No. 117, S. D. 1, H. D. 1, t o r equest t he Gover nor t o
convene a t ask f or ce compr i sed of consumer s of publ i c ment al
heal t h ser vi ces, t he Hospi t al st af f member s, and r epr esent at i ves
27
Hel en Al t onn, Federal magistrate to oversee state hospital, Honol ul u St ar
Bul l et i n ( May 18, 2001) .
28
Ken Kobayashi , Feds to end oversight at state mental hospital, Honol ul u
Adver t i ser ( November 13, 2004) .
29
Uni t ed St at es v. St at e of Hawai i , et al . , Or der Di smi ssi ng Act i on wi t h
Pr ej udi ce, Ci vi l No. 91- 00137 DAE/ KSC ( 2006) ( LR_07_0324- 0326) .

of st at e and count y gover nment agenci es and advocacy agenci es t o
eval uat e and r ecommend possi bl e pr ocedur al , st at ut or y, and
publ i c pol i cy changes t o mi ni mi ze t he census of t he Hospi t al as
wel l as t o pr omot e devel opment of communi t y- based ser vi ces f or
f or ensi c ment al heal t h consumer s. The t ask f or ce was r equest ed
t o consi der a number of i ssues,
30
i ncl udi ng communi t y- based
ment al heal t h ser vi ces f or f or ensi c pat i ent s condi t i onal l y
r el eased by t he cour t s; ment al heal t h i nt er vent i ons and j ai l
di ver si on pr ogr ams t o assi st ment al l y i l l i ndi vi dual s who come
i nt o cont act wi t h t he cr i mi nal j ust i ce syst em; chapt er 704, HRS;
t he J udi ci ar y' s Ment al Heal t h Cour t ; f or ensi c ment al heal t h
exami ner s; and post - r el ease af t er - car e ser vi ces f or sever el y and
per si st ent l y ment al l y i l l i ncar cer at ed pat i ent s.

The t ask f or ce convened i n Oct ober 2006 and met mont hl y
unt i l concl udi ng i n November 2007. As a r esul t of i t s year l ong
ef f or t , t he t ask f or ce made r ecommendat i ons i n t hr ee ar eas
chapt er 704, HRS, t i mef r ames; or der s t o t r eat ( i nvol unt ar y
medi cat i on) ; and ment al heal t h exami nat i ons
31
and each ar ea
i ncl uded r ecommendat i ons f or publ i c pol i cy, st at ut or y, and
pr ocedur al changes.

b. Governor's Special Action Team

On J une 14, 2012, t he Gover nor i ssued an Execut i ve
Memor andum
32
t o convene a Speci al Act i on Teamt o addr ess t he
i ncr easi ng census at t he Hospi t al . I n t he memor andum, t he
Gover nor st at ed t hat i n t he l ast si x mont hs, t he mont hl y number
of admi ssi ons t o t he Hospi t al i ncr eased by 50%wi t h no
cor r espondi ng i ncr ease i n t he r at e of di schar ge, whi ch r ai sed
concer ns t hat pat i ent car e may be compr omi sed as a r esul t . The
Speci al Act i on Teamwas convened t o conduct an anal ysi s of t he
causes of t he hi gh census at t he Hospi t al , consi der opt i ons t o
addr ess t he causes, devel op a pr i or i t y l i st of r ecommendat i ons
f or changes, pr opose shor t - and l ong- t er msol ut i ons, and pr ovi de
a summar y r epor t t o t he Gover nor .

Over a f i ve- week per i od f r omJ ul y 17, 2012, t o August 21,
2012, t he Speci al Act i on Teamf ocused i t s wor k on ar eas t o
r ecommend f or act i on and consi der at i on by t he Gover nor ' s
30
See, S. C. R. No. 117, S. D. 1, H. D. 1 ( Regul ar Sessi on of 2006) .
31
Promote Community-Based Health Services for Forensic Patients ( December
2007) .
32
See, Depar t ment of Heal t h, Special Action Team Report to the Governor on
Revitalization of the Adult Mental Health System and Effective Management of
the Hawaii Hospital Census ( Oct ober 2012) .

Admi ni st r at i on f or t he 2013 l egi sl at i ve sessi on and t he bi enni um
budget . The Speci al Act i on Teamwas compr i sed of t hr ee
subcommi t t ees cover i ng t he f ol l owi ng ar eas: per sonnel , f i nance,
and pr ocur ement ; pr ogr amcapaci t y and cl i ni cal oper at i ons; and
l egal and j udi ci al .

The Speci al Act i on Teami dent i f i ed sever al syst emi c
f act or s, i ncl udi ng t he use of t he Hospi t al t o pr ovi de t he
maj or i t y of i npat i ent psychi at r i c t r eat ment i n t he St at e, unl i ke
most of t he ot her st at es; t he ver y hi gh f or ensi c use of t he
Hospi t al , unl i ke ot her st at es; and t he unexpl ai ned i ncr ease i n
t he r at e of f or ensi c eval uat i ons or der ed by Hawai i cour t s dur i ng
FY2012. The r ecommendat i ons of t he Speci al Act i on Teamwer e
devel oped by t he t hr ee subcommi t t ees and wer e di vi ded i nt o
shor t - t er mr ecommendat i ons t hat woul d be subst ant i al l y
i mpl ement ed i n FY2013 and l ong- t er mr ecommendat i ons t hat coul d
be i mpl ement ed i n FY2014 and beyond. I n gener al , t hese
r ecommendat i ons f ocused on devel opi ng communi t y r esour ces, whi ch
i s mor e cost ef f ect i ve t han i npat i ent hospi t al i zat i on, and
maki ng t he f or ensi c pr ocess mor e ef f i ci ent and ef f ect i ve.

3. Legislative Intervention

The Legi sl at ur e al so assi st ed i n cr eat i ng and i mpr ovi ng t he
Hospi t al by i mpl ement i ng r ecommendat i ons made by t he t ask f or ce
est abl i shed pur suant t o S. C. R. No. 117 ( Regul ar Sessi on of 2006)
and t he Gover nor ' s Speci al Act i on Team. Fur t her mor e, t he
Legi sl at ur e al so act ed as an appr opr i at e venue t o r ecei ve
i nf or mat i on r egar di ng t he Hospi t al and addr ess pr obl ems t hr ough
l egi sl at i on.

a. Reported Staff Assaults in 2007

I n ear l y August 2007, medi a cover age
33
cal l ed at t ent i on t o a
J anuar y 2007 i nci dent i nvol vi ng an i nj ur y t o a Hospi t al nur se by
one of her pat i ent s and t he r esi gnat i on of t he st af f
psychi at r i st on account of her saf et y concer ns at t he Hospi t al .
Nur se Ter r y Evans, who suf f er ed f aci al i nj ur i es, i ncl udi ng a
br oken or bi t al bone ar ound her l ef t eye, cl ai med her i nj ur i es
r esul t ed f r oman unsaf e wor kpl ace and t hat she cont i nued t o
suf f er f r ompost - t r aumat i c st r ess syndr ome. For mer st af f
psychi at r i st , Dr . Kar en Ri t chi e, st at ed, " I f i nal l y deci ded I
coul dn' t cont i nue t o wor k t her e because I don' t bel i eve i t ' s a
saf e envi r onment , "
34
i n comment i ng about her r esi gnat i on.

33
B. J . Reyes, State hospital staff labors in fear, Honol ul u St ar Bul l et i n
( August 7, 2007) .
34
I d.

As a r esul t , t he Legi sl at ur e hel d a news conf er ence t o
bui l d awar eness of t he gr owi ng number of assaul t s by pat i ent s
agai nst st af f at t he Hospi t al . Accor di ng t o t he medi a r epor t ,
35

t he Depar t ment of Heal t h r epor t ed t hat dur i ng t he f i r st si x
mont hs of 2007, t her e wer e 107 assaul t s by pat i ent s agai nst
st af f member s. I n t he year s l eadi ng up t o t he l egi sl at i ve news
conf er ence i t was r epor t ed t hat 187 assaul t s occur r ed i n 2006,
133 assaul t s i n 2005, and 170 assaul t s i n 2004.
36
The number of
r epor t ed assaul t s has f l uct uat ed over t he past f ew year s. The
i ncr eased i nci dence of pat i ent s assaul t i ng st af f was at t r i but ed
t o an i ncr ease i n t he pat i ent census, par t i cul ar l y due t o t he
i ncr ease i n t he cour t - or der ed f or ensi c ment al heal t h pat i ent s.
Legi sl at or s expr essed concer n t hat i f t hese occur r ences at t he
Hospi t al cont i nued, a f at al i t y woul d occur .

b. Act 100, Session Laws of Hawaii 2008

Dur i ng t he Regul ar Sessi on of 2008, t he Legi sl at ur e passed
Act 100 i n r esponse t o t he r ecommendat i ons made by t he t ask
f or ce pur suant t o S. C. R. No. 117 ( Regul ar Sessi on of 2006) and
t o addr ess t he r ecent r i se i n i nci dence of pat i ent s assaul t i ng
st af f at t he Hospi t al . The pur pose sect i on of par t I I of Act
100, Sessi on Laws of Hawai i 2008, not ed t hat pat i ent - t o- st af f
assaul t s at t he Hospi t al was an ar ea of hei ght ened
or gani zat i onal f ocus and publ i c scr ut i ny. As a r esul t , Act 100
37

amended 707- 711, HRS, t o est abl i sh cr i mi nal char ges agai nst a
per son who i nt ent i onal l y or knowi ngl y causes bodi l y i nj ur y t o a
per son empl oyed i n a st at e- oper at ed or - cont r act ed ment al heal t h
f aci l i t y as a cl ass C f el ony. Pr i or t o Act 100, such an assaul t
woul d gener al l y be a mi sdemeanor .

c. Informational Briefings in 2014

Si nce t he enact ment of Act 100,
38
t he Legi sl at ur e has
per i odi cal l y r ecei ved i nf or mat i on on i nst ances of Hospi t al st af f
i nj ur i es; f ai l ur e or r ef usal t o at t end t o, t r eat , or moni t or
i nst ances of st af f i nj ur i es caused by pat i ent s at t he Hospi t al ;
and al l egat i ons of empl oyment i mpr opr i et i es by admi ni st r at i ve
and super vi sor y per sonnel . On November 20, 2013, sever al
Hospi t al empl oyees r epor t ed at a pr ess conf er ence t hei r concer ns
r egar di ng wor kpl ace saf et y i nvol vi ng at t acks on empl oyees by
pat i ent s, and al l eged empl oyment i mpr opr i et i es. At t hat t i me,
Senat or s cal l ed f or a pr obe i nt o t he assaul t s by pat i ent s on
Hospi t al st af f .

35
I d.
36
I d.
37
See, Par t I I , Act 100, Sessi on Laws of Hawai i 2008, and 707- 711, HRS.
38
Act 100, Sessi on Laws of Hawai i 2008.

On J anuar y 7, 2014, t he Senat e Commi t t ees on Heal t h and
J udi ci ar y and Labor hel d an i nf or mat i onal br i ef i ng t o r ecei ve an
updat e on t he st at e of vi ol ence agai nst Hospi t al wor ker s,
expl or e st af f i ng pat t er ns at t he Hospi t al and pl ans t o cr eat e a
saf e wor kpl ace, and r ecei ve i nf or mat i on about t he spect r umof
pat i ent s, i ncl udi ng vi ol ent of f ender s, at t he Hospi t al . At t hi s
i nf or mat i onal br i ef i ng, t he Senat e Commi t t ees r ecei ved
i nf or mat i on f r omt he Depar t ment of Heal t h, Depar t ment of Labor
and I ndust r i al Rel at i ons, Depar t ment of Publ i c Saf et y,
J udi ci ar y, and sever al i nj ur ed Hospi t al wor ker s and a medi cal
physi ci an.

The Senat e Commi t t ees on Heal t h and J udi ci ar y and Labor
hel d a second i nf or mat i onal br i ef i ng on J anuar y 27, 2014, t o
r ecei ve updat ed i nf or mat i on f r omdepar t ment heads, as r equest ed
dur i ng t he pr evi ous i nf or mat i onal br i ef i ng, and addi t i onal
i nf or mat i on on t he st at e of wor kpl ace vi ol ence at t he Hospi t al .
The Senat e Commi t t ees r ecei ved i nf or mat i on f r omt he Depar t ment
of Publ i c Saf et y, Depar t ment of Labor and I ndust r i al Rel at i ons,
Depar t ment of Human Resour ces Devel opment , Depar t ment of t he
At t or ney Gener al , and Depar t ment of Heal t h. At t hi s
i nf or mat i onal br i ef i ng, i t was not ed by t he Chai r per sons of t he
Senat e Commi t t ees on Heal t h and J udi ci ar y and Labor t hat t he
Commi t t ee Chai r per sons i nt r oduced S. R. No. 3 on J anuar y 17,
2014, f or adopt i on by t he Senat e and t hat t hi s r esol ut i on woul d
est abl i sh a Senat e Speci al I nvest i gat i ve Commi t t ee.

B. SENATE RESOLUTION NO. 3 (REGULAR SESSION OF 2014)

I n l i ght of t he l ongst andi ng pr obl ems at t he Hospi t al
despi t e f eder al , execut i ve, and l egi sl at i ve i nt er vent i on, and
due t o t he r ecent i nf or mat i on r egar di ng wor kpl ace vi ol ence at
t he Hospi t al and t he al l egat i ons of empl oyment i mpr opr i et i es,
t he Senat e adopt ed S. R. No. 3 ( Regul ar Sessi on of 2014) t o
est abl i sh a Senat e Speci al I nvest i gat i ve Commi t t ee pur suant t o
chapt er 21, HRS.

1. Objectives and Powers of the Investigative Committee

Under S. R. No. 3, t he obj ect i ves of t he Senat e Speci al
I nvest i gat i ve Commi t t ee ( I nvest i gat i ve Commi t t ee) i ncl uded t he
f ol l owi ng:

( 1) I nvest i gat e t he wor kpl ace saf et y of al l Hospi t al
psychi at r i c wor ker s;

( 2) I nvest i gat e t he al l eged Hospi t al admi ni st r at i ve and
empl oyment i mpr opr i et i es; and

( 3) I nqui r e i nt o, gat her , and anal yze i nf or mat i on,
i ncl udi ng t he Hospi t al ' s per sonnel f i l es, t hat may
pr ovi de r el evant i nf or mat i on concer ni ng wor ker saf et y
and al l eged admi ni st r at i ve i mpr opr i et i es.

Under S. R. No. 3, t he I nvest i gat i ve Commi t t ee was
aut hor i zed ever y power and f unct i on al l owed t o an i nvest i gat i ve
commi t t ee speci f i ed under chapt er 21, HRS, i ncl udi ng wi t hout
l i mi t at i on t he power t o:

( 1) Adopt r ul es f or t he conduct of i t s pr oceedi ngs;

( 2) I ssue subpoenas r equi r i ng t he at t endance and t est i mony
of wi t nesses and subpoenas duces t ecumr equi r i ng t he
pr oduct i on of books, document s, r ecor ds, paper s, or
ot her evi dence i n any mat t er pendi ng bef or e t he
I nvest i gat i ve Commi t t ee;

( 3) Hol d hear i ngs appr opr i at e f or t he per f or mance of i t s
dut i es at such t i mes and pl aces as t he I nvest i gat i ve
Commi t t ee det er mi nes;

( 4) Admi ni st er oat hs and af f i r mat i ons t o wi t nesses at
hear i ngs of t he I nvest i gat i ve Commi t t ee;

( 5) Repor t or cer t i f y i nst ances of cont empt as pr ovi ded
under 21- 14, HRS;

( 6) Det er mi ne t he means by whi ch a r ecor d shal l be made of
i t s pr oceedi ngs i n whi ch t est i mony or ot her evi dence
i s demanded or adduced; and

( 7) Pr ovi de f or t he submi ssi on, by a wi t ness' s own counsel
and counsel f or anot her i ndi vi dual or ent i t y about
whomt he wi t ness has devot ed subst ant i al or i mpor t ant
por t i ons of t he wi t ness' s t est i mony, of wr i t t en
quest i ons t o be asked of t he wi t ness by t he Chai r .

2. Members of the Investigative Committee

As set f or t h i n S. R. No. 3, t he member shi p of t he
I nvest i gat i ve Commi t t ee compr i sed not l ess t han f i ve member s,
i ncl udi ng t he Chai r per sons of t he Senat e Commi t t ees on Heal t h
and J udi ci ar y and Labor , appoi nt ed by t he Pr esi dent of t he
Senat e. The member s of t he I nvest i gat i ve Commi t t ee ar e Senat or
Cl ayt on Hee, Co- Chai r ; Senat or J osh Gr een, Co- Chai r ; Senat or
Mai l e S. L. Shi mabukur o; Senat or Rosal yn H. Baker ; and Senat or
SamSl om.

3. Hearings and Subpoenas

I n t he cour se of i t s i nvest i gat i on t he I nvest i gat i ve
Commi t t ee hel d hear i ngs t o r ecei ve i nf or mat i on f r omsubpoenaed
wi t nesses and al so subpoenaed r el evant document s. The t est i mony
r ecei ved was gi ven subj ect t o subpoena and made under oat h,
subj ect t o t he penal t y f or per j ur y, whi ch i ncl udes a ci vi l f i ne
up t o $1, 000 or i mpr i sonment up t o one year .

As par t of i t s i nvest i gat i on, t he I nvest i gat i ve Commi t t ee
conduct ed 10 hear i ngs l ast i ng over a t ot al of 19 hour s and
r ecei ved t est i mony f r om14 wi t nesses. I n addi t i on, t he
I nvest i gat i ve Commi t t ee r ecei ved i n excess of 12, 000 pages of
document s i n r esponse t o subpoenas. Unl ess ot her wi se not ed, t he
wr i t t en f i ndi ngs and r ecommendat i ons of t he I nvest i gat i ve
Commi t t ee cont ai ned i n t hi s r epor t r el i ed upon t he t est i mony
hear d by t he I nvest i gat i ve Commi t t ee under oat h or f r om
document s r ecei ved pur suant t o a subpoena.

PART III.
FINDINGS OF THE SENATE SPECIAL INVESTIGATIVE COMMITTEE

S. R. No. 3 not es t hat on November 20, 2013, sever al
Hospi t al empl oyees i nf or med Senat or s about t hei r concer ns about
wor kpl ace saf et y i nvol vi ng at t acks on empl oyees and of al l eged
admi ni st r at i ve and empl oyment i mpr opr i et i es at t he Hospi t al .
The I nvest i gat i ve Commi t t ee t akes t hese concer ns ser i ousl y and
not es t hat i t s f or mat i on i s cr edi t ed t o t hese Hospi t al empl oyees
st eppi ng f or war d t o shed l i ght on l ongst andi ng pr obl ems at t he
Hospi t al .

I n t he cour se of i t s di scussi on and assessment of t he
document s and t est i mony i t r ecei ved, t he I nvest i gat i ve Commi t t ee
f i nds t hat t he Hospi t al f aces t hr ee mai n chal l enges. These
chal l enges ar e r el at ed t o each ot her and i ncl ude:

A. Mai nt ai ni ng a saf e wor k envi r onment f or Hospi t al st af f
and pat i ent s;

B. Meet i ng t he cur r ent needs of Hospi t al pat i ent s and
st af f due t o i nef f i ci ent use of f aci l i t i es and pat i ent
and st af f saf et y pr act i ces; and

C. Pr ovi di ng ef f i ci ent and ef f ect i ve human r esour ces
pr act i ces.

These chal l enges and t hei r r el at ed f i ndi ngs ar e di scussed
i n t he f ol l owi ng sect i ons.

A. CHALLENGES IN MAINTAINING A SAFE WORK ENVIRONMENT FOR
HOSPITAL STAFF AND PATIENTS

The I nvest i gat i ve Commi t t ee f i nds t hat t he Hospi t al has
l ongst andi ng pr obl ems mai nt ai ni ng a saf e wor k envi r onment f or
i t s st af f and pat i ent s. The par amount wor kpl ace saf et y i ssue
appear s t o be vi ol ent and unst abl e pat i ent s at t acki ng st af f and
causi ng i nj ur i es.

1. Continued Reports of Patients Assaulting Staff

The I nvest i gat i ve Commi t t ee f i nds t hat despi t e l egi sl at i ve
i nt er vent i on, t he Hospi t al cont i nues t o have r epor t s of pat i ent s
assaul t i ng st af f or ot her pat i ent s. The Hospi t al uses a br oad
and i ncl usi ve def i ni t i on of assaul t t o capt ur e i nf or mat i on about
pat i ent cl i ni cal pr ogr ess or ant i ci pat e change i n cl i ni cal
st at us pr i or t o an ext r eme behavi or al event . The Hospi t al
def i nes assaul t as " any over t act ( physi cal cont act ) upon t he
per son of anot her t hat may or does r esul t i n physi cal i nj ur y
and/ or emot i onal di st r ess. Exampl es i ncl ude, but ar e not
l i mi t ed t o hi t s, spi t s, sexual assaul t s, or any physi cal i nj ur y
i nt ent i onal l y i nf l i ct ed upon anot her per son. "
39

The I nvest i gat i ve Commi t t ee f ur t her f i nds t hat assaul t s on
Hospi t al empl oyees have r esul t ed i n some empl oyees bei ng out of
wor k f or mont hs and even year s, whi ch cont r i but es t o st af f
shor t ages. For exampl e, i n J anuar y 2007, Nur se Ter r y Evans
suf f er ed f aci al i nj ur i es, i ncl udi ng a br oken or bi t al bone ar ound
her l ef t eye.
40
She cl ai med t hat her i nj ur i es r esul t ed f r oman
unsaf e wor kpl ace and t hat she cont i nued t o suf f er f r ompost -
t r aumat i c st r ess syndr ome.
41
As a r esul t of t he assaul t , Ms.
Evans no l onger wor ks at t he Hospi t al . On December 3, 2009,
f or mer Uni t T Psychi at r i c Techni ci an, Emel i nda Yar t e sust ai ned
i nj ur i es t o her head and j aw whi l e she assi st ed her cowor ker s i n
cont r ol l i ng a vi ol ent and unst abl e pat i ent .
42
Si nce sust ai ni ng
her i nj ur i es, Ms. Yar t e has not r et ur ned t o t he Hospi t al .
43
I n
December 2011, a Psychi at r i c Techni ci an was at t acked by a
pat i ent and sust ai ned mul t i pl e unpr ovoked punches t o t he f ace,
whi ch r esul t ed i n a l acer at i on over t he empl oyee' s l ef t eye.
44

Thi s empl oyee was out of wor k f or si x mont hs. The I nvest i gat i ve
Commi t t ee not es t hat t hese ar e onl y a handf ul of i nci dent s t hat
have occur r ed at t he Hospi t al . Fi gur e 3. 1 i ndi cat es t he number
of pat i ent - t o- st af f assaul t s f r omyear s 2006 t o 2013.

39
Depar t ment of Heal t h, Assaul t Management and Psychol ogi cal Fi r st Ai d Pol i cy
and Pr ocedur e No. 14. 040 ( LR_01_121013_0016- 0027 - Conf i dent i al ) .
40
( August 7, 2007) .
41
( August 7, 2007) .
42
Test i mony of Emel i nda Yar t e, May 14, 2014.
43
44
Depar t ment of Heal t h, Document at i on of a Psychi at r i c Techni ci an Assaul t ed
by Pat i ent i n t he PI CU ( LR_07_091614_1- 9) .

Figure 3.1
Patient-to-Staff Assaults at the Hospital

Year No. of Assaults
2006 187
2007 179
2008 150
2009 164
2010 140
2011 132
2012 120
2013 135

45

The I nvest i gat i ve Commi t t ee f i nds t hat t he Hospi t al i s
unabl e t o adequat el y addr ess t hi s pr obl embecause t he Hospi t al
cannot accur at el y assess t he br eadt h of t he pr obl emdue t o
i nconsi st ent r epor t i ng of assaul t s on st af f . I n addi t i on, t he
Hospi t al has under ut i l i zed t ool s t hat coul d assi st i t i n
pr event i ng assaul t s or mi t i gat i ng t he ser i ousness of assaul t s.

a. Inconsistent Reporting of Assaults on Staff

The I nvest i gat i ve Commi t t ee i s deepl y concer ned r egar di ng
t he number of assaul t s on st af f but i s unabl e t o det er mi ne t he
br eadt h and per vasi veness of t he pr obl em. The I nvest i gat i ve
Commi t t ee f i nds t hat t he number of r epor t s of pat i ent s
assaul t i ng st af f ar e i naccur at e due t o i nconsi st ent or l ack of
r epor t i ng. The I nvest i gat i ve Commi t t ee f ur t her f i nds t hat t he
i nconsi st ent r epor t i ng of pat i ent assaul t s on st af f can be
at t r i but ed t o a number of f act or s, i ncl udi ng conf l i ct i ng dat a,
st af f f ai l i ng t o r epor t assaul t s, and i nef f i ci ent communi cat i on
of pat i ent assaul t s on st af f up t he chai n of command i n t he
Depar t ment of Heal t h.

The I nvest i gat i ve Commi t t ee r ecei ved conf l i ct i ng dat a
r egar di ng assaul t s by pat i ent s. The Depar t ment of Heal t h
submi t t ed t o t he I nvest i gat i ve Commi t t ee i nf or mat i on and
st at i st i cs r egar di ng st af f saf et y compl ai nt s, j ob- r el at ed
i nj ur i es, and wor ker s' compensat i on cl ai ms f r om2009 t o t he
pr esent .
46
Whi l e i t appr eci at es t he amount of i nf or mat i on
r ecei ved f r omt he Depar t ment , t he I nvest i gat i ve Commi t t ee i s
45
Depar t ment of Heal t h, I nf or mat i on Regar di ng t he Accur acy of t he St at i st i c
t hat Assaul t s Occur Once Ever y Thr ee Days ( LR_01_011514_0006- 0009 -
Conf i dent i al ) .
46
Depar t ment of Heal t h, I nf or mat i on and St at i st i cs Regar di ng St af f Saf et y
Compl ai nt s, J ob- Rel at ed I nj ur i es, and Wor ker s' Compensat i on Cl ai ms f r om2009
t o t he Pr esent ( LR_15_0001- 0070 Conf i dent i al ) .

unabl e t o det er mi ne how t he l i st of empl oyee i nci dent r epor t s
cor r el at e wi t h t he l i st of st af f i nj ur y r epor t s because some
empl oyee i nci dent r epor t s, whi ch i ndi cat e t hat an i nj ur y was
sust ai ned, ar e not document ed under t he l i st of st af f i nj ur y
r epor t s and vi ce ver sa. Fur t her mor e, under t he l i st of st af f
i nj ur y r epor t s, t he number of assaul t s per year t hat wer e f i l ed
f or r ecor ds onl y or wor ker s' compensat i on does not cor r el at e
wi t h and i s l ess t han t he number of pat i ent - t o- st af f assaul t s
per year r epor t ed by t he Depar t ment under Fi gur e 3. 1. The
I nvest i gat i ve Commi t t ee does not bel i eve t hat t he t ot al number
of assaul t s occur r i ng at t he Hospi t al can be l ess t han t he
number of pat i ent - t o- st af f assaul t s. Accor di ngl y, t he
I nvest i gat i ve Commi t t ee does not under st and how t he Depar t ment
of Heal t h det er mi ned t he number of pat i ent - t o- st af f assaul t s at
t he Hospi t al and quest i ons t he accur acy of t he number s pr ovi ded
under Fi gur e 3. 1.

Accor di ng t o t he Depar t ment of Heal t h, t he event r epor t i ng
pr ocess assur es t hat assaul t s ar e document ed so t hat act i on may
be t aken, i f appr opr i at e, and i deal l y t o pr event a sever e
event .
47
However , t he I nvest i gat i ve Commi t t ee f i nds t hat t he
pol i ci es and pr ocedur es f or r epor t i ng i nci dent s of assaul t s ar e
not wi del y i mpl ement ed by st af f because st af f vi ew assaul t s by
pat i ent s as par t of t hei r j ob.
48
Dur i ng t he I nvest i gat i ve
Commi t t ee' s si t e vi si t of t he Hospi t al i n J une 2014, empl oyees
di scl osed i nci dent s wher e t hey wer e assaul t ed by a pat i ent , but
di d not f i l e an empl oyee i nci dent r epor t because t hey di d not
sust ai n any i nj ur i es, or i f t he assaul t r esul t ed i n an i nj ur y,
t hey di d not t hi nk t he i nj ur y was ser i ous enough t o war r ant a
r epor t , especi al l y compar ed t o ser i ous i nj ur i es ot her empl oyees
pr evi ousl y sust ai ned.
49
The I nvest i gat i ve Commi t t ee f i nds t hat
t hese comment s ar e pecul i ar and concer ni ng, and i ndi cat i ve of
t he cul t ur e of wor kpl ace vi ol ence at t he Hospi t al . As such, t he
f ai l ur e of st af f t o f i l e r epor t s cont r i but es t o t he i naccur at e
r epor t s of assaul t s by pat i ent s.

The I nvest i gat i ve Commi t t ee f i nds t hat del ays i n and
pr obl ems wi t h f i l i ng cl ai ms f or wor ker s' compensat i on and
r ecei vi ng wor ker s' compensat i on benef i t s may del ay i nj ur ed st af f
f r omr et ur ni ng t o wor k i n a t i mel y manner and r esul t i n gr eat er
cost s f or t he St at e. Fur t her mor e, a f or mer Hospi t al empl oyee
t est i f i ed t hat she di d not r ecei ve wor ker s' compensat i on
47
Depar t ment of Heal t h, I nf or mat i on Regar di ng t he Accur acy of t he St at i st i c
t hat Assaul t s Occur Once Ever y Thr ee Days ( LR_01_011514_0006- 0009 -
48
Comment s by I nvest i gat i ve Commi t t ee r egar di ng Si t e Vi si t on J une 11, 2014
( J ul y 16, 2014) .
49
Comment s by I nvest i gat i ve Commi t t ee r egar di ng Si t e Vi si t on J une 11, 2014
( J ul y 16, 2014) .

payment s f or a per i od of f i ve mont hs.
50
As a r esul t , t hi s
empl oyee hi r ed an at t or ney t o assi st her i n r ecei vi ng her back
payment s.
51
Al t hough her wor ker s' compensat i on cl ai mwas
appr oved t hr ee days af t er she sust ai ned her i nj ur i es, t he
empl oyee t est i f i ed t hat she knew i nj ur ed cowor ker s who wai t ed
one t o t hr ee mont hs f or t hei r cl ai ms t o be appr oved and r ecei ve
t r eat ment s f or t hei r i nj ur i es.
52
The I nvest i gat i ve Commi t t ee i s
concer ned t hat del ays i n wor ker s' compensat i on may di scour age
i nj ur ed st af f f r omr epor t i ng assaul t s t o avoi d bei ng mi r ed i n
t he wor ker s' compensat i on pr ocess, i ncl udi ng havi ng t o hi r e an
at t or ney t o expedi t e t he pr ocess.

The I nvest i gat i ve Commi t t ee f i nds t hat Depar t ment of Heal t h
admi ni st r at or s do not have an accur at e number of assaul t s t hat
occur at t he Hospi t al because onl y cer t ai n i nf or mat i on r egar di ng
assaul t s i s r epor t ed up t he chai n of command. The Deput y
Di r ect or of Behavi or al Heal t h, Lynn Fal l i n, t est i f i ed t hat she
r ecei ves r epor t s of onl y ser i ous assaul t s f r omt he Admi ni st r at or
of t he Adul t Ment al Heal t h Di vi si on, Dr . Mar k Fr i dovi ch.
53
A
ser i ous assaul t i s def i ned by Depar t ment and Hospi t al
admi ni st r at or s as an assaul t t hat r esul t s i n a ser i ous i nj ur y
t hat r equi r es out si de medi cal at t ent i on ot her t han what t he
Hospi t al can pr ovi de, such as an i nj ur y t hat r equi r es emer gency
r oommedi cal at t ent i on.
54
Ms. Fal l i n t est i f i ed t hat si nce she
became Deput y Di r ect or i n J ul y 2011, she has r ecei ved f our
al er t s about ser i ous assaul t s occur r i ng at t he Hospi t al .
55
The
I nvest i gat i ve Commi t t ee bel i eves t hat bei ng awar e of onl y t he
ser i ous assaul t s hi nder s t he Depar t ment admi ni st r at i on' s abi l i t y
t o assess t he br eadt h of t he pr obl emand devel op and i mpl ement
appr opr i at e and ef f ect i ve r ecommendat i ons f or l ar ge- scal e
changes f or t he Hospi t al . Fur t her mor e, t he I nvest i gat i ve
Commi t t ee has concer ns t hat by r epor t i ng onl y t he ser i ous
assaul t s t o Ms. Fal l i n, Dr . Fr i dovi ch may be mi ni mal i zi ng t he
number of assaul t s t hat occur at t he Hospi t al and cont r i but i ng
t o t he i naccur at e number of r epor t s of assaul t s by pat i ent s.

Fur t her mor e, t he I nvest i gat i ve Commi t t ee f i nds t hat whi l e
t he Hospi t al has i t s own def i ni t i ons f or at t empt ed assaul t and
assaul t ,
56
i t appear s t hat Depar t ment of Heal t h admi ni st r at or s do
not have a cl ear under st andi ng or consi st ent use of t hese
def i ni t i ons and how t hey ar e used t o t r ack and r epor t assaul t s
50
Test i mony, May 14, 2014.
51
52
53
Test i mony of Lynn Fal l i n, Mar ch 27, 2014.
54
Test i mony of Lynn Fal l i n, Mar ch 27, 2014; and Test i mony of Wi l l i amEl l i ot t ,
J ul y 16, 2014.
55
56
Depar t ment of Heal t h, Assaul t Management and Psychol ogi cal Fi r st Ai d Pol i cy
and Pr ocedur e No. 14. 040 ( LR_01_121013_0016- 0027 - Conf i dent i al ) .

occur r i ng at t he Hospi t al . The Di r ect or of Heal t h was unabl e t o
cl ear l y ar t i cul at e t o t he I nvest i gat i ve Commi t t ee t he
di f f er ences bet ween t he t wo act s and l ar gel y r el i ed on whet her
any medi cal at t ent i on was sought by t he assaul t vi ct i mor t he
l evel of medi cal car e t hat was necessar y t o di f f er ent i at e t he
t wo act s.
57
The I nvest i gat i ve Commi t t ee bel i eves t hat t he
t r acki ng and r epor t i ng of assaul t s shoul d be based on an
est abl i shed set of def i ni t i ons wi t h cl ear cr i t er i a set t i ng out
t he t ype of act i on, and ext ent and t ype of i nj ur y necessar y t o
const i t ut e an at t empt ed assaul t or assaul t r at her t han whet her
any medi cal at t ent i on or car e was sought or needed. The
I nvest i gat i ve Commi t t ee wonder s whet her t he Hospi t al i s t r acki ng
and r epor t i ng assaul t s t o Depar t ment admi ni st r at or s accor di ng t o
i t s est abl i shed def i ni t i ons of assaul t , whi ch t he I nvest i gat i ve
Commi t t ee f i nds l acki ng of cl ear cr i t er i a, or anot her set of
cr i t er i a t hat i s based on t he ext ent of medi cal at t ent i on
needed. Wi t hout a cl ear under st andi ng of how assaul t s ar e
def i ned and t r acked, Depar t ment admi ni st r at or s ar e unabl e t o
devel op and i mpl ement l ar ge- scal e pl ans t o addr ess t he pr obl em
of assaul t s occur r i ng at t he Hospi t al .

b. Underutilization of Act 100

I n 2008, t he Legi sl at ur e not ed under par t I I of Act 100,
Sessi on Laws of Hawai i 2008( Act 100) ,
58
t hat pat i ent - t o- st af f
assaul t s at t he Hospi t al was an ar ea of hei ght ened
or gani zat i onal f ocus and publ i c scr ut i ny. As a r esul t , t he
Legi sl at ur e amended 707- 711, HRS, t o est abl i sh cr i mi nal char ges
agai nst a per son who i nt ent i onal l y or knowi ngl y causes bodi l y
i nj ur y t o a per son empl oyed i n a st at e- oper at ed or - cont r act ed
ment al heal t h f aci l i t y as a cl ass C f el ony.
59
However , t he
I nvest i gat i ve Commi t t ee f i nds t hat Act 100 has not been used
si nce i t became ef f ect i ve on J ul y 1, 2008.

Accor di ng t o t he Depar t ment of Heal t h, t her e have been
" f our i nst ances of pr osecut i ons advanci ng subsequent t o t he
enact ment of t he r evi sed st at ut e i n 2008. "
60
Al so f or mer Act i ng
Admi ni st r at or , Wi l l i amEl l i ot , sent a l et t er dat ed J anuar y 9,
2014, t o t he Honol ul u Pol i ce Depar t ment ( HPD) r equest i ng a
l i st i ng of assaul t s on Hospi t al st af f r epor t ed t o HPD, i ncl udi ng
HPD r epor t number s, assaul t event descr i pt i on, and dat e of
i nci dent f r om2008 t o t he pr esent .
61
However , t o dat e, t he
57
Test i mony of Dr . Li nda Rosen, J ul y 16, 2014.
58
59
60
Depar t ment of Heal t h, Number of Ti mes Act 100 was Used by Hospi t al Wor ker s
( LR_01_011514_0003- 0005) .
61
( LR_01_011514_0003- 0005) .

Hospi t al has not r ecei ved a r esponse f r omHPD, even af t er a
f ol l ow- up r equest was made by Associ at e Admi ni st r at or f or
Cl i ni cal Ser vi ces, Dr . Wi l l i amSheehan, on Sept ember 11, 2014.
62

The I nvest i gat i ve Commi t t ee has concer ns r egar di ng what
appear s t o be an under ut i l i zat i on of Act 100. The meani ng of
" f our i nst ances of pr osecut i ons advanci ng"
63
i s uncl ear t o t he
I nvest i gat i ve Commi t t ee and t he absence of a r esponse f r omHPD
f ai l s t o pr ovi de cl ar i t y. However , i f t he " f our i nst ances" i s
an accur at e number of t i mes t hat Act 100 has been used by
Hospi t al st af f , t hen t he I nvest i gat i ve Commi t t ee quest i ons why
Act 100 has not been used mor e, especi al l y i n l i ght of t he
number of assaul t s on st af f t hat occur r ed at t he Hospi t al ,
whet her Hospi t al st af f i s awar e of Act 100, and whet her Hospi t al
admi ni st r at i on educat es st af f of t hei r l egal opt i ons i f t hey ar e
assaul t ed by a pat i ent whi l e at t he Hospi t al .

c. Lack of Appropriate Training to Handle Violent
Patients

I n addi t i on t o t he i nconsi st ent r epor t i ng of assaul t s on
st af f , t he I nvest i gat i ve Commi t t ee f i nds t hat empl oyees ar e i l l -
pr epar ed t o handl e vi ol ent pat i ent s due t o a l ack of appr opr i at e
t r ai ni ng. Upon bei ng hi r ed, al l Hospi t al st af f ar e r equi r ed t o
compl et e 10 hour s of Conf l i ct Pr event i on, Management , and
Resol ut i on ( CPMR) t r ai ni ng on how t o empl oy de- escal at i on
t echni ques
64
and r ecei ve annual t r ai ni ng t her eaf t er . However ,
t he Hawai i Occupat i onal Saf et y and Heal t h Di vi si on of t he
Depar t ment of Labor and I ndust r i al Rel at i ons ( HI OSH) r ecent l y
f ound t hat t he CPMR t r ai ni ng and pr act i ce dr i l l s wer e not
r eal i st i c or pr act i cal enough t o pr epar e empl oyees f or t he r eal -
l i f e si t uat i ons t hat t hey may encount er wi t h vi ol ent , unst abl e
pat i ent s.
65
I n l i ght of t he hi gh pat i ent census and t he spect r um
of f or ensi c ment al heal t h pat i ent s at t he Hospi t al , t he
I nvest i gat i ve Commi t t ee st r ongl y bel i eves t hat pr ovi di ng st af f
wi t h t he appr opr i at e t r ai ni ng t o pr event assaul t s or de- escal at e
a si t uat i on wi l l assi st i n decr easi ng t he number of assaul t s on
st af f or ot her pat i ent s and t he sever i t y of assaul t s.

62
Depar t ment of Heal t h, Document at i on Regar di ng Response f r omHPD on Act 100
( LR_06_091614_1- 2) .
63
( LR_01_011514_0003- 0005) .
64
Power Poi nt mat er i al s submi t t ed by t he Depar t ment of Heal t h t o t he Senat e
Commi t t ees on Heal t h and J udi ci ar y and Labor f or t he I nf or mat i onal Br i ef i ng
on J anuar y 7, 2014 ( LR_01_0033- 0061) .
65
Depar t ment of Labor and I ndust r i al Rel at i ons, Ci t at i on and Not i f i cat i on of
Penal t y, HI OSH I nspect i on Number 316273333 ( Apr i l 10, 2014) .

2. Recently Cited for Occupational Safety and Health
Violations

The I nvest i gat i ve Commi t t ee f i nds t hat on Apr i l 10, 2014,
HI OSH i ssued t o t he Hospi t al seven ser i ous occupat i onal saf et y
and heal t h ci t at i ons wi t h f i nes t ot al i ng $40, 700.
66
The
I nvest i gat i ve Commi t t ee speci f i cal l y not es t he f ol l owi ng
f i ndi ngs f r omt he HI OSH Ci t at i on and Not i f i cat i on of Penal t y
r epor t :
67

" The empl oyer di d not f ur ni sh empl oyment f r ee f r om
r ecogni zed hazar ds t hat wer e l i kel y t o cause deat h or
ser i ous physi cal har mi n t hat t hei r empl oyees wer e
exposed t o t he hazar d of bei ng physi cal l y assaul t ed by
t hei r own pat i ent s. "
68

" Mul t i pl e empl oyees di d not know about , under st and, or
r et ai n t he knowl edge t o el i mi nat e and cont r ol hazar ds
associ at ed wi t h wor ki ng i n an envi r onment wi t h
assaul t i ve, unst abl e pat i ent s. Mor e i mpr oved
wor kpl ace vi ol ence t r ai ni ng i s needed t o deal wi t h t he
hi gh i nci dent r at es of pat i ent t o st af f assaul t s. "
69

" Some empl oyees ar e non- r esponsi ve i n doi ng t hei r j ob
when PMT/ Code 200 cal l s ar e made. Saf et y pr act i ces
wer e not under scor ed t hr ough cor r ect i on of unsaf e
per f or mance. "
70

The I nvest i gat i ve Commi t t ee not es t hat t he Depar t ment of
Heal t h i s cur r ent l y i n t he pr ocess of cont est i ng t hese ci t at i ons
and a hear i ng dat e has not been set yet . Dr . Rosen t est i f i ed
t hat t he Depar t ment was cont est i ng cer t ai n i t ems under t he HI OSH
ci t at i on and t he Depar t ment of Labor and I ndust r i al Rel at i ons
( DLI R) had agr eed t o di smi ss one of t hese i t ems.
71
However , t he
I nvest i gat i ve Commi t t ee subsequent l y di scover ed f r omDLI R t hat
t he ent i r e HI OSH ci t at i on must be cont est ed, not j ust cer t ai n
i t ems.
72
Thus, none of t he i t ems wer e di smi ssed.
73
Accor di ngl y,
66
67
68
69
70
71
72
Commi t t ee Di scussi on, J ul y 30, 2014.
73
Commi t t ee Di scussi on, J ul y 30, 2014.

t he I nvest i gat i ve Commi t t ee i s concer ned wi t h t he Di r ect or of
Heal t h' s and Depar t ment of Heal t h' s l ack of under st andi ng of
HI OSH vi ol at i on pr ocedur es.

Fur t her mor e, t he I nvest i gat i ve Commi t t ee i s deepl y
concer ned r egar di ng t he HI OSH f i ndi ng t hat empl oyees di d not
know about , under st and, or r et ai n knowl edge t o el i mi nat e and
cont r ol hazar ds associ at ed wi t h wor ki ng at t he Hospi t al . Thi s
l ack of knowl edge and under st andi ng i s i ndi cat i ve of t he
Hospi t al admi ni st r at i on' s f ai l ur e t o devel op and i mpl ement
ef f ect i ve pol i ci es and pr ocedur es t o ensur e a saf e wor k
envi r onment f or i t s st af f . The I nvest i gat i ve Commi t t ee st r ongl y
ur ges t he Hospi t al t o make a ser i ous ef f or t i n addr essi ng and
r esol vi ng t hese HI OSH vi ol at i ons r at her t han on cont est i ng and
mi t i gat i ng t he vi ol at i ons and t he associ at ed penal t i es.

B. CHALLENGES IN MEETING THE CURRENT NEEDS OF HOSPITAL
PATIENTS AND STAFF DUE TO INEFFICIENT USE OF FACILITIES AND
PATIENT AND STAFF SAFETY PRACTICES

The I nvest i gat i ve Commi t t ee f i nds t hat t he desi gn,
i nf r ast r uct ur e, and t echnol ogy of t he Hospi t al no l onger
ef f ect i vel y meet t he t her apeut i c ment al heal t h needs of i t s
pat i ent s. Addi t i onal l y, t he Hospi t al ' s hi gh pat i ent census,
whi ch i s ent i r el y compr i sed of f or ensi c ment al heal t h pat i ent s,
poses a const ant chal l enge f or t he Hospi t al t o f i nd enough beds
as wel l as suf f i ci ent st af f i ng t o pr ovi de adequat e pat i ent car e.
However , t he Hospi t al i s f or ced t o admi t , accommodat e, and t r eat
pat i ent s wi t h l i mi t ed r esour ces, whi ch cont r i but es t o saf et y
concer ns f or t he pat i ent s, st af f , and sur r oundi ng communi t y.

1. Inefficient Use of Hospital Facilities

The Hospi t al i s accr edi t ed as an acut e car e f aci l i t y.
74
The
Hospi t al has 202 l i censed beds
75
and 40 addi t i onal suppl ement al
adul t i npat i ent psychi at r i c beds or over f l ow beds under cont r act
wi t h Kahi Mohal a Behavi or al Heal t h.
76
The aver age dai l y census
at t he hospi t al f or cal endar year 2013 was 192 pat i ent s.
However , t he per - day census t ypi cal l y r eaches over 200 pat i ent s
dependi ng on t he number of f or ensi c admi ssi ons. Ther ef or e, t he
I nvest i gat i ve Commi t t ee f i nds t hat t he per si st ent l y hi gh census
and t he l egal r equi r ement s i mposed by t he Cl ar k per manent
74
Depar t ment of Heal t h, Accr edi t at i on Aut hor i t i es, Requi r ement s, and Cycl es
( LR_04_0001- 0193) .
75
on J anuar y 7, 2014 ( LR_01_0033- 0061) .
76
I d.

i nj unct i on
77
pl ace addi t i onal st r ess on Hospi t al f aci l i t y use,
whi ch i mpact s pat i ent car e, and st af f i ng needs.

a. High Patient Census and Facility Limitations
Impact Patient Unit Assignments

The I nvest i gat i ve Commi t t ee f i nds t hat a pat i ent ' s uni t
pl acement can be based on bed avai l abi l i t y or f aci l i t y
accommodat i ons r at her t han on t he pat i ent ' s cl i ni cal need. The
Hospi t al oper at es f i ve r ehabi l i t at i on i npat i ent uni t s ( Uni t s E,
I , S, T, and U) t hat gener al l y ser ve t he l onger - t er mneeds of
pat i ent s and t wo acut e psychi at r i c car e uni t s ( Uni t s F and H) .
Upon admi ssi on and st abi l i zat i on, a pat i ent i s assi gned t o one
of t hese uni t s f or t r eat ment and r ehabi l i t at i on. Except f or t he
acut e psychi at r i c car e uni t s and t he al l - mal e uni t , t he ot her
uni t s ar e not desi gnat ed f or any speci f i c t ypes of pat i ent s.
Thus, each uni t may accommodat e a wi de spect r umof pat i ent s wi t h
var i ous cl i ni cal needs as l ong as t her e i s a bed avai l abl e and
t he uni t i nf r ast r uct ur e i s abl e t o accommodat e t he pat i ent .

Upon admi ssi on t o t he Hospi t al , each pat i ent i s assi gned t o
a t r eat ment t eamcompr i sed of a psychi at r i st , psychol ogi st ,
nur se, and ot her member s who meet dai l y t o cr eat e, r evi ew, and
updat e, i f necessar y, a t r eat ment pl an f or t he pat i ent .
78
The
t r eat ment t eamcol l abor at es wi t h t he Uni t Nur se Manager s t o
det er mi ne whi ch uni t i s t he most appr opr i at e f or t he pat i ent ' s
cl i ni cal needs accor di ng t o t he pat i ent ' s t r eat ment pl an.
However , accor di ng t o Uni t U Nur se Manager , Vi vi an Cayet ano, a
pat i ent ' s uni t assi gnment i s mor e l i kel y t o be based on bed
avai l abi l i t y r at her t han cl i ni cal need.
79
She expl ai ned t hat
because t he Hospi t al i s over census and beyond capaci t y, t he
Hospi t al i s f or ced t o move pat i ent s t o ot her uni t s t o make r oom
f or newl y admi t t ed pat i ent s i n Uni t H and, i f necessar y, use
cl assr ooms and meet i ng r ooms f or pat i ent r ooms.
80

The I nvest i gat i ve Commi t t ee f i nds t hat t he Hospi t al ' s
desi gn and i nf r ast r uct ur e al so have an i mpact on pat i ent uni t
assi gnment s. For exampl e, pat i ent s who ar e medi cal l y
compr omi sed ar e gener al l y assi gned t o uni t s t hat do not have a
l ot of st ai r s or ar e cl oser t o t he Tr eat ment Mal l , whi ch i s
l ocat ed on t he l ower par t of t he Hospi t al campus.
81
Fur t her mor e,
t he I nvest i gat i ve Commi t t ee not es t hat Uni t U i s l i mi t ed t o onl y
mal e pat i ent s. Al t hough i t accept s mal e pat i ent s wi t h a wi de
77
Cl ar k v. St at e of Hawai i , St i pul at i on f or Amended Per manent I nj unct i on, No.
CV 99- 00885 DAE/ BMK ( 2003) ( LR_07_0033- 0040) .
78
Test i mony of Vi vi an Cayet ano, May 28, 2014.
79
80
81

spect r umof cl i ni cal needs, t he uni t t ends t o accommodat e mal e
pat i ent s who ar e char ged wi t h or convi ct ed of sexual cr i mes or
exhi bi t or have a hi st or y of i nappr opr i at e sexual behavi or s.
82

Uni t U has addi t i onal l i mi t at i ons, such as si ze, one communi t y
bat hr oom, r ooms wi t h t wo t o f our pat i ent s, and st ai r s, whi ch can
i mpact pat i ent assi gnment s. Last l y, t he use of cl assr oomand
meet i ng r ooms f or pat i ent r ooms al so has i t s own l i mi t at i ons as
t hese r ooms ar e not desi gned as pat i ent r ooms and ar e usual l y
mor e appr opr i at e f or l ow r i sk pat i ent s.

The I nvest i gat i ve Commi t t ee i s concer ned t hat t he evi dent
pol i cy f or pat i ent assi gnment s, whi ch i s based l ar gel y on bed
avai l abi l i t y, i s not i n t he best i nt er est s of t he pat i ent or t he
ot her pat i ent s and st af f on t he assi gned uni t , and may r esul t i n
an i ncr ease i n pat i ent and st af f saf et y r i sks. As a r esul t of
t he hi gh pat i ent census, t he I nvest i gat i ve Commi t t ee has
concer ns r egar di ng t he pr essur e a t r eat ment t eami s under t o
f i nd an avai l abl e bed when det er mi ni ng a pat i ent ' s uni t
assi gnment . The I nvest i gat i ve Commi t t ee bel i eves t hat
cl assi f yi ng and assi gni ng pat i ent s t o uni t s based on cl i ni cal
need r at her t han ot her f act or s, such as bed avai l abi l i t y, wi l l
assi st i n ensur i ng appr opr i at e uni t assi gnment s as wel l as
pat i ent and st af f saf et y.

b. Overutilization of Unit H to Serve Dual Purposes

Uni t H ser ves as one of t he t wo acut e t r eat ment uni t s as
wel l as t he admi ssi on uni t f or al l pat i ent s admi t t ed t o t he
Hospi t al .
83
Due t o t he l i mi t ed bed avai l abi l i t y i n Uni t H, t he
Hospi t al moves pat i ent s t o ot her uni t s bef or e t he pat i ent s ar e
st abl e and r eady f or t r ansf er t o make r oomf or newl y admi t t ed
pat i ent s who ar e or der ed by t he cour t f or eval uat i on or
t r eat ment at t he Hospi t al .
84
concer ned t hat i nt r oduci ng unst abl e pat i ent s i nt o st abl e pat i ent
popul at i ons bef or e t hese unst abl e pat i ent s ar e cl i ni cal l y r eady
i ncr eases t he saf et y r i sks f or t he pat i ent s and st af f .

The pr obl emof bed avai l abi l i t y on Uni t H i s compounded by
t he number of pat i ent s admi t t ed t o t he Hospi t al . The dai l y
count of admi t t ed pat i ent s i s l ar gel y dependent on t he
Hospi t al ' s l egal r equi r ement s of t he Cl ar k per manent
i nj unct i on.
85
Accor di ng t o t he Depar t ment of Heal t h, t he number
of f or ensi c admi ssi ons has i ncr eased f r om2009 t o 2013. Fi gur e
3. 2 i l l ust r at es t he number and t ype of admi ssi ons and t he
82
83
Depar t ment of Heal t h, Document s Det ai l i ng t he PI CU ( LR_08_091614_1- 41) .
84
85
Cl ar k v. St at e of Hawai i , St i pul at i on f or Amended Per manent I nj unct i on;
Or der , No. CV 99- 00885 DAE/ BMK ( 2003) .

per cent age i ncr ease f r om2009 t o 2013 as r epor t ed by t he
Depar t ment of Heal t h.

Figure 3.2
Number of Admissions from 2009 to 2013

Year
Not Guilty by
Reason of
Insanity
Evaluation of
Fitness
Restoration of
Fitness
72-Hour
Hold/Conditional
Release
2009 16 29 91 73
2010 8 29 96 82
2011 20 29 74 84
2012 13 60 120 89
2013 23 50 146 99
% Increase from
2009 to 2013 44% 72% 60% 36%

86

The number of admi t t ed f or ensi c pat i ent s not onl y i ncr eases
on a year l y basi s, but al so f l uct uat es on a dai l y basi s as t he
Hospi t al f ul f i l l s i t s l egal r equi r ement s by admi t t i ng cour t
or der ed pat i ent s. Ther ef or e, t he I nvest i gat i ve Commi t t ee f i nds
t hat t he i ncr ease and f l uct uat i on of admi t t ed pat i ent s poses a
chal l enge f or t he Hospi t al t o accur at el y pl an and pr epar e f or
t he number of beds t hat ar e needed t o accommodat e al l of i t s
admi t t ed pat i ent s on Uni t H i n addi t i on t o t he acut e pat i ent s
bei ng t r eat ed on Uni t H t her eby i ncr easi ng t he need t o move
pat i ent s t o ot her uni t s.

The I nvest i gat i ve Commi t t ee has concer ns r egar di ng Uni t H
ser vi ng a dual pur pose as an acut e psychi at r i c car e uni t and as
t he admi ssi ons uni t f or t he ent i r e Hospi t al . Whi l e i t
r ecogni zes t hat space i s l i mi t ed at t he Hospi t al , t he
I nvest i gat i ve Commi t t ee bel i eves t hat admi t t ed pat i ent s and
acut e psychi at r i c pat i ent s can be bet t er ser ved and t r eat ed
separ at el y and t hat desi gnat i ng Uni t H as an admi ssi ons- onl y
uni t wi l l assi st t he Hospi t al i n i ncr easi ng t he number of beds
avai l abl e f or admi t t ed pat i ent s and decr easi ng t he need t o
t r ansf er unst abl e pat i ent s t o st abl e r ehabi l i t at i on uni t s.
Accor di ngl y, Uni t H st af f wi l l be abl e t o mor e ef f ect i vel y meet
t he car e and t r eat ment needs of i t s admi t t ed pat i ent s whi l e
decr easi ng t he saf et y r i sks.

86
on J anuar y 7, 2014 ( LR_01_0033- 0061) .

The I nvest i gat i ve Commi t t ee not es t hat t he Hospi t al i s
accr edi t ed as an acut e car e f aci l i t y.
87
However , i n l i ght of t he
f or ensi c pat i ent admi ssi ons and census, t he I nvest i gat i ve
Commi t t ee of f er s f or consi der at i on t he quest i on of whet her a
f or ensi c car e desi gnat i on and accr edi t at i on may bet t er ser ve t he
pur poses of t he Hospi t al .

c. Underutilization of a Feasible Option to Address
the Needs of High Risk or Violent Patients

The I nvest i gat i ve Commi t t ee f i nds t hat t he Hospi t al
under ut i l i zes a f easi bl e opt i on t hat woul d pr ovi de f or t he
t r ansf er of cer t ai n hi gh r i sk or vi ol ent pat i ent s t o anot her
ment al heal t h f aci l i t y cont r act ed by t he St at e f or appr opr i at e
t r eat ment and r ehabi l i t at i on. The I nvest i gat i ve Commi t t ee not es
t hat t her e ar e cur r ent l y t wo hi gh r i sk pat i ent s who wer e
t r ansf er r ed t o GEO Car e, I nc. ' s Col umbi a Regi onal Car e Cent er , a
f or ensi c ment al heal t h f aci l i t y i n Sout h Car ol i na.
88
The
Hospi t al det er mi ned t hat t hese t wo pat i ent s needed t o be car ed
f or at a f or ensi c hospi t al - t ype cor r ect i onal f aci l i t y t hat
pr ovi ded ment al and physi cal heal t h ser vi ces r at her t han an
acut e psychi at r i c hospi t al - t ype cl i ni cal f aci l i t y l i ke t he
Hospi t al .
89
The Hospi t al f ur t her det er mi ned t hat t hese pat i ent s
and si mi l ar pat i ent s woul d be bet t er managed at a f aci l i t y
out si de of t he St at e t hat i s speci f i cal l y desi gned t o bet t er
meet t he needs of t he pat i ent s whi l e cr eat i ng a saf er
envi r onment f or ot her Hospi t al pat i ent s, Hospi t al st af f , and t he
t r ansf er r ed pat i ent .
90
The I nvest i gat i ve Commi t t ee f ur t her not es
t hat one of t he pat i ent s who was t r ansf er r ed t o t he Sout h
Car ol i na f aci l i t y had been i nst i t ut i onal i zed at t he Hal awa
Cor r ect i onal Faci l i t y af t er ser i ousl y assaul t i ng a Hospi t al
st af f member .
91

The I nvest i gat i ve Commi t t ee f i nds t hat t he t r ansf er of
pat i ent s t o Sout h Car ol i na f or t r eat ment i s a cost - ef f ect i ve
opt i on t hat woul d pr ovi de t he appr opr i at e l evel of car e f or t he
t r ansf er r ed pat i ent , assi st i n cont r ol l i ng pat i ent census, and
cont r i but e t o a saf er wor k envi r onment . Fi gur e 3. 3 i l l ust r at es
t he pat i ent cost per day f or a pat i ent hospi t al i zed at t he
87
Depar t ment of Heal t h, Accr edi t at i on Aut hor i t i es, Requi r ement s, and Cycl es
( LR_04_0001- 0193) .
88
Depar t ment of Heal t h, Document at i on Rel at i ng t o t he Cont r act wi t h GEO Car e,
I nc. , Col umbi a Regi onal Car e Cent er ( LR_03_071614_0001- 0072) .
89
90
91

Hospi t al , Kahi Mohal a ( f or a cont r act ed over f l ow bed) , and GEO
Car e, I nc. f aci l i t y i n Sout h Car ol i na.

Figure 3.3
Patient Cost per Day

Location Cost per Day
Hawaii State Hospital $657.97
Kahi Mohala $745.00
(for up to 40 beds)

$800.00
(for acute care)
GEO Care, Inc. $304.00
to
$425.00
(three daily rates depending
on level of acuity)

92

The I nvest i gat i ve Commi t t ee not es t hat t he Hospi t al
r eal i zes a cost savi ngs of appr oxi mat el y $350 t o $230 per day
per pat i ent t o hospi t al i ze a pat i ent at t he f aci l i t y i n Sout h
Car ol i na compar ed t o t he Hospi t al , t hus savi ng t he Hospi t al and
St at e money.

I n addi t i on t o t he cost savi ngs, t he I nvest i gat i ve
Commi t t ee not es t hat t he number of vi ol ent assaul t s agai nst
Hospi t al pat i ent s and st af f ar e commi t t ed by a smal l handf ul of
pat i ent s. The Di r ect or of Heal t h, Dr . Rosen, est i mat ed t hat 5%
of t he pat i ent popul at i on i s r esponsi bl e f or a number of t he
vi ol ent assaul t s and poses a gr eat er danger at t he Hospi t al .
93

Thus, f or a pat i ent popul at i on of 200 pat i ent s, appr oxi mat el y 10
pat i ent s ar e r esponsi bl e f or commi t t i ng a number of Hospi t al
assaul t s. However , t he Admi ni st r at or of t he Adul t Ment al Heal t h
Di vi si on, Dr . Fr i dovi ch, cl ar i f i ed t hat t hi s est i mat i on may
change f r ommont h- t o- mont h or week- t o- week dependi ng on pat i ent
pr ogr ess i n t r eat ment .
94
However , t he I nvest i gat i ve Commi t t ee
bel i eves t hat such est i mat e i s t oo hi gh consi der i ng t he number
of assaul t s t hat have occur r ed at t he Hospi t al , especi al l y when
opt i ons ar e avai l abl e t o ensur e t hat vi ol ent pat i ent s r ecei ve
t he appr opr i at e and necessar y l evel of car e whi l e ensur i ng
wor kpl ace saf et y. The f or ensi c ment al heal t h f aci l i t y i n Sout h
Car ol i na pr ovi des ment al and physi cal heal t h ser vi ces t hat ar e
92
Depar t ment of Heal t h, Pat i ent Cost per Day at HSH, Kahi Mohal a, and GEO
Car e, I nc. ( LR_01_071614_0001, LR_02_071614_0002, and LR_03_071614_0001) .
93
94
Test i mony of Dr . Mar k Fr i dovi ch, J ul y 16, 2014.

mor e appr opr i at e t han t he ser vi ces t hat t he Hospi t al i s abl e t o
pr ovi de f or such pat i ent s. Fur t her mor e, t r ansf er r i ng hi gh r i sk
or vi ol ent pat i ent s wi l l pr ovi de a saf er envi r onment f or
Hospi t al pat i ent s and st af f and assi st i n cont r ol l i ng t he
per si st ent l y hi gh pat i ent census.

Despi t e t he appar ent benef i t s, t he I nvest i gat i ve Commi t t ee
f i nds t hat si nce 2010, t he Hospi t al has t r ansf er r ed onl y t wo
pat i ent s t o Sout h Car ol i na f or t r eat ment . The I nvest i gat i ve
Commi t t ee not es t hat a t hi r d pat i ent was consi der ed f or t r ansf er
i n Mar ch 2014.
95
However , Dr . Fr i dovi ch hel d t he r equest f or
t r ansf er because t he " Hospi t al l acked a wr i t t en pol i cy and
pr ocedur e t hat woul d gover n and descr i be t he cr i t er i a and t he
ci r cumst ances under whi ch i ndi vi dual s shoul d be consi der ed f or
t hat ki nd of speci al t r eat ment . "
96
The wr i t t en pol i ci es and
pr ocedur es woul d descr i be t he consi der at i ons t hat must be t aken
i nt o account i n r evi ewi ng a pat i ent f or pot ent i al t r ansf er ,
i ncl udi ng cl i ni cal needs and al t er nat i ves, l egal st at us and
ot her consi der at i ons, i nt er nal and ext er nal consul t at i on, and
r el at i ve and ot her soci al suppor t .
97
Dr . Fr i dovi ch expl ai ned
t hat f or t he ot her t wo pat i ent s who wer e t r ansf er r ed t o t he
Sout h Car ol i na f aci l i t y wi t hout a wr i t t en pol i cy and pr ocedur e,
t hese det er mi nat i ons wer e based on a case- speci f i c r evi ew, not
an occur r ence i nvol vi ng t he pat i ent . The Associ at e
Admi ni st r at or f or Cl i ni cal Ser vi ces, Dr . Sheehan, f ur t her
expl ai ned t hat t he deci si ons t o t r ansf er t he t wo pat i ent s wer e
" done empi r i cal l y, meani ng t hat t her e wer e ot her f act or s t hat
came i nt o pl ay on cases t hat r esul t ed i n t he deci si on bei ng made
t o t r ansf er an i ndi vi dual t o t he mai nl and" and done wi t h " heavy
admi ni st r at i ve eval uat i on, and maybe not qui t e as st r ong
cl i ni cal eval uat i on. "
98

As a r esul t , Dr . Fr i dovi ch r ecommended t hat a set of
pol i ci es and pr ocedur es be devel oped and i mpl ement ed bef or e any
mor e pat i ent s wer e t r ansf er r ed t o Sout h Car ol i na f or t r eat ment .
99

However , t he I nvest i gat i ve Commi t t ee not es t hat Dr . Fr i dovi ch
ser ved as t he Hospi t al Admi ni st r at or when t he f i r st pat i ent was
t r ansf er r ed t o t he Sout h Car ol i na f aci l i t y. Thus, despi t e Dr .
Sheehan' s expl anat i on, i t i s st i l l uncl ear t o t he I nvest i gat i ve
Commi t t ee why he hel d t he t hi r d pat i ent t r ansf er r equest i n
Mar ch 2014, when Dr . Fr i dovi ch was par t l y r esponsi bl e f or
t r ansf er r i ng t he f i r st pat i ent i n 2010 when no pol i ci es and
pr ocedur es t o t r ansf er pat i ent s out - of - st at e exi st ed.

95
96
97
98
Test i mony of Dr . Wi l l i amSheehan, J ul y 30, 2014.
99

The I nvest i gat i ve Commi t t ee f ur t her not es t hat as of August
20, 2014, t he Hospi t al has made ef f ect i ve a new pol i cy and
pr ocedur e f or t he assessment of pat i ent s deemed unabl e t o be
saf el y t r eat ed at t he Hospi t al t o be t r ansf er r ed t o a cont r act ed
out - of - st at e f aci l i t y.
100
cont empl at es how l ong i t woul d t ake t he Hospi t al t o devel op and
i mpl ement t hese pol i ci es and pr ocedur es had i t not been f or t he
I nvest i gat i ve Commi t t ee' s i nsi st ence t hat t he Hospi t al expedi t e
t hei r ef f or t s.

Dr . Rosen
101
and new Hospi t al Admi ni st r at or , Wi l l i amMay,
102

t est i f i ed t hat t he Hospi t al has a dut y t o car e f or i t s pat i ent s
i n Hawai i . However , t he I nvest i gat i ve Commi t t ee st r ongl y
bel i eves t hat t he opt i on of t r ansf er r i ng hi gh r i sk pat i ent s t o
t he mai nl and i s a cost - ef f ect i ve and f easi bl e t ool t hat t he
Hospi t al shoul d have t he l at i t ude t o use, especi al l y when such
pat i ent s pose a r i sk t o t hemsel ves or ot her s and can r ecei ve
mor e appr opr i at e t r eat ment and r ehabi l i t at i on t hat t he Hospi t al
i s unabl e t o pr ovi de. The I nvest i gat i ve Commi t t ee ur ges t he
Hospi t al t o use t hi s opt i on when appr opr i at e.

d. Safety Concerns Close a Psychiatric Unit

ef f or t s t o cont r ol i t s hi gh pat i ent census and ensur e a saf e
wor k envi r onment ar e f ur t her hi nder ed by t he cl osi ng of t he
Psychi at r i c I nt ensi ve Car e Uni t ( PI CU) . I n 2011, Uni t F was
r enovat ed at t he cost of $530, 000 t o cr eat e t he PI CU,
103
a f our -
bed sui t e of f of t he mai n uni t , as par t of a pl an t o combi ne t he
f unct i ons of Uni t s F and H i nt o an Acut e Ser vi ces Pr ogr am.
104

Under t hi s pr ogr am, t he admi ssi on f unct i ons of Uni t H woul d be
di vi ded wher eby Uni t F woul d t ake t he l i ght admi ssi ons and Uni t
H woul d cont i nue t o accept acut e admi ssi ons, t hus i ncr easi ng t he
Hospi t al ' s admi ssi ons bed count .
105
The PI CU was i nt ended t o
r educe r i sk on t he acut e ser vi ces uni t s ( Uni t s F and H) by
assi gni ng hi gh r i sk pat i ent s t o t he PI CU upon admi ssi on and as
needed f or car e, t r eat ment , and saf et y.
106
Thi s pl acement woul d
pr event t he i nt r oduct i on of unst abl e hi gh r i sk pat i ent s i nt o t he
uni t popul at i ons bef or e t hey ar e cl i ni cal l y r eady, t her eby
100
Depar t ment of Heal t h, Pol i cy and Pr ocedur e on Tr ansf er r i ng HSH Pat i ent s t o
Ot her Faci l i t i es Out si de t he St at e ( LR_02_091614_1- 6) .
101
Test i mony of Dr . Rosen, J ul y 16, 2014.
102
Test i mony of Wi l l i amMay, J ul y 30, 2014.
103
on J anuar y 7, 2014 ( LR_01_0033- 0061) .
104
105
106

cr eat i ng a saf er envi r onment f or pat i ent s and st af f .
107
PI CU
pat i ent s woul d be r est r i ct ed f r omt he admi ssi on ar eas unt i l t hey
wer e st abi l i zed and r eady t o st ep down t o t he appr opr i at e
admi ssi on uni t .
108
However , t he PI CU was i l l - desi gned and t he
st r uct ur e was never r eady t o be pr oper l y i mpl ement ed i nt o t he
Hospi t al ' s oper at i ons. On December 1, 2011, a Psychi at r i c
Techni ci an ( Psych Tech) was per f or mi ng a 1: 1 assi gnment wi t h a
pat i ent who was admi t t ed t o t he PI CU.
109
The Psych Tech was
at t acked by t he pat i ent and r ecei ved mul t i pl e unpr ovoked punches
t o t he f ace and head, whi ch r esul t ed i n a l acer at i on over t he
Psych Tech' s l ef t eye.
110
Shor t l y t her eaf t er , t he PI CU was
cl osed f or saf et y r easons and concer ns r ai sed by st af f and l abor
uni on r epr esent at i ves.
111

Whi l e t he I nvest i gat i ve Commi t t ee under st ands t he i mpor t ant
dut y f or t he Hospi t al t o ensur e a saf e wor k envi r onment , i t has
concer ns r egar di ng t he l engt h of t i me t hat t he PI CU has been
cl osed. The PI CU was i nt ended f or hi gh r i sk pat i ent s, and
del ays i n addr essi ng t he saf et y pr obl ems r esul t i n t he Hospi t al
bei ng f or ced t o combi ne hi gh r i sk pat i ent s wi t h ot her acut e
pat i ent s i n Uni t s F and H, whi ch may cr eat e a hi gher saf et y r i sk
f or t hese uni t s. Si nce t he PI CU' s cl osi ng, i t has been used
onl y a f ew t i mes f or l ow r i sk pat i ent s as r equi r ed by pat i ent
census
112
and not used f or i t s i nt ended pur pose. The
I nvest i gat i ve Commi t t ee not es t hat t he Hospi t al has sent l et t er s
f or consul t at i on t o HGEA and UPW
113
and t her ef or e st r ongl y ur ges
t he Hospi t al and uni ons t o addr ess t he saf et y concer ns t o enabl e
use of t he PI CU as a r esour ce f or t he saf e management of
pat i ent s who pr esent behavi or al changes.

2. Insufficient Security to Protect Patients, Staff, and
Surrounding Community

Whi l e t he I nvest i gat i ve Commi t t ee r ecogni zes t hat t he
Hospi t al ' s pur pose i s t o t r eat and r ehabi l i t at e r at her t han
i ncar cer at e i ndi vi dual s suf f er i ng f r ombr ai n, medi cal , and
behavi or al di sor der s, i t al so r ecogni zes t hat t he Hospi t al i s
107
108
109
110
111
on J anuar y 7, 2014 ( LR_01_0033- 0061) .
112
on J anuar y 7, 2014 ( LR_01_0033- 0061) .
113

aut hor i zed by l aw
114
t o be a st at e- oper at ed secur e psychi at r i c
r ehabi l i t at i on pr ogr amf or i ndi vi dual s who r equi r e i nt ensi ve
t her apeut i c t r eat ment and r ehabi l i t at i on i n a secur e set t i ng,
i ncl udi ng f or ensi c ment al heal t h pat i ent s who ar e hospi t al i zed
pur suant t o a cour t or der . Accor di ngl y, i t i s i mper at i ve f or
t he Hospi t al t o mai nt ai n a saf e and secur e f aci l i t y. However ,
t he I nvest i gat i ve Commi t t ee f i nds t hat cer t ai n ar eas of t he
Hospi t al ' s secur i t y need i mpr ovement and st r engt heni ng t o ensur e
a saf e envi r onment f or pat i ent s t o r ecei ve t r eat ment , st af f t o
pr ovi de pat i ent car e, and t he sur r oundi ng communi t y t o coexi st
wi t h t he Hospi t al .

a. Inadequate Monitoring and Operation of Security
Cameras

Ther e ar e over 140 secur i t y camer as t hr oughout t he ent i r e
Hospi t al campus, whi ch ar e al l moni t or ed by one secur i t y of f i cer
st at i oned at t he Hospi t al ' s Tel ecommuni cat i on Of f i ce.
115
Thi s
of f i cer i s i n char ge of moni t or i ng t he l ower l evel
admi ni st r at i on ar ea and al l ext er i or camer as dur i ng Tr eat ment
Mal l hour s and al l upper and l ower uni t s dur i ng non- Tr eat ment
Mal l hour s. Mor eover , t hi s of f i cer i s r esponsi bl e f or
posi t i oni ng and moni t or i ng al l ext er i or camer as dur i ng a code 77
( r esponse code f or a pat i ent el opement , el opement at t empt , or
absent wi t hout l eave)
116
t o sear ch f or a pat i ent , acknowl edgi ng
al l door al ar ms t hat become act i ve or ar e l ef t open by st af f or
a pat i ent , and posi t i oni ng t he camer a t o t he l ocat i on of a code
200 ( r esponse code t o mobi l i ze st af f t o an ar ea whet her t her e i s
a r i sk f or har mby a pat i ent t owar d sel f , ot her s, or pr oper t y)
117

t o assi st t he r esponse t eami n l ocat i ng, assessi ng, and
r espondi ng t o t he si t uat i on. The I nvest i gat i ve Commi t t ee has
st r ong concer ns r egar di ng t he assi gned r esponsi bi l i t y of
moni t or i ng over 140 secur i t y camer as t o j ust one of f i cer . The
I nvest i gat i ve Commi t t ee f i nds t hat t hi s i s t oo l ar ge and
i mpor t ant of a r esponsi bi l i t y t o pl ace on onl y one i ndi vi dual
because cl osed ci r cui t vi deo moni t or i ng i mpact s emer gency and
secur i t y r esponse t i mes as wel l as ef f or t s t o pr event an
emer gency si t uat i on or secur i t y br each.

Fur t her mor e, dur i ng t he I nvest i gat i ve Commi t t ee' s si t e
vi si t of t he Hospi t al i n J une 2014, i t obser ved t hat not al l of
t he camer as wer e const ant l y wor ki ng. Hospi t al admi ni st r at or s
114
See, 334- 2. 5, HRS.
115
Depar t ment of Heal t h, I nf or mat i on on t he Moni t or i ng of Cl osed Ci r cui t Vi deo
at t he HSH ( LR_01_011514_1123- 1138 Conf i dent i al ) .
116
Depar t ment of Heal t h, El opement , El opement At t empt , and AWOL Pol i cy and
Pr ocedur e No. 19. 520 ( LR_01_020714_0067- 0082 Conf i dent i al ) .
117
Depar t ment of Heal t h, Code 200 and Backup Cal l s Pol i cy and Pr ocedur e No.
09. 030 ( LR_01_121013_0028- 0037 Conf i dent i al ) .

expl ai ned t hat some of t he camer as wer e of f because no pat i ent s
wer e cur r ent l y i n t he camer a' s vi ew r ange. The I nvest i gat i ve
Commi t t ee does not under st and t hi s j ust i f i cat i on because i t
bel i eves t hat al l camer as shoul d be on at al l t i mes.
Fur t her mor e, t he I nvest i gat i ve Commi t t ee i s concer ned about how
camer a i nact i vi t y may af f ect emer gency or secur i t y r esponse
t i mes, especi al l y when i t was r epor t ed by Emel i nda Yar t e,
118
a
f or mer Hospi t al Psychi at r i c Techni ci an who was i nj ur ed by a
pat i ent i n December 2009, t hat not al l of t he secur i t y camer as
wer e oper at i ng at t he t i me she sust ai ned her i nj ur i es. She
t est i f i ed t hat i f al l of t he secur i t y camer as had been wor ki ng,
t he camer as woul d have been abl e t o bet t er capt ur e and r ecor d
t he i nci dent
119
f or Hospi t al r ecor ds. The I nvest i gat i ve
Commi t t ee f i nds t hat ensur i ng t hat al l secur i t y camer as ar e
oper at i ng at al l t i mes bet t er enabl es t he Hospi t al t o pr event or
r espond t o emer genci es as wel l as keep a r ecor d f or t he Hospi t al
f or r i sk management pur poses.

b. Issues Regarding the Personal Mobile Transmitter
(PMT) Devices

The I nvest i gat i ve Commi t t ee not es t hat t her e ar e i ssues
r egar di ng t he PMT devi ces.
120
The PMT devi ce al l ows a per son t o
summon f or assi st ance qui ckl y wi t hout t he use of a t el ephone
when dur ess or a har mf ul si t uat i on occur s.
121
Code 200 i s a
r esponse code t o mobi l i ze st af f t o an ar ea whet her t her e i s a
r i sk f or har mby a pat i ent t owar d sel f , ot her s, or pr oper t y.
122

Ther ef or e, t he PMT devi ces ar e a vi t al pi ece of saf et y equi pment
f or t he pr ot ect i on of pat i ent s and st af f f r omhar m, and al l
empl oyees ar e r equi r ed t o wear t hei r devi ces at al l t i mes when
on dut y.
123

The I nvest i gat i ve Commi t t ee has ser i ous concer ns r egar di ng
an i nci dent of an empl oyee wor ki ng at t he PI CU sust ai ni ng
ser i ous i nj ur i es t o t he head and f ace as a r esul t of an
unpr ovoked at t ack by a pat i ent .
124
I t i s r epor t ed t hat t hi s
empl oyee' s PMT devi ce f ai l ed t o wor k pr oper l y and t hus, t he
118
119
120
on J anuar y 7, 2014 ( LR_01_0033- 0061) .
121
09. 030 ( LR_01_121013_0028- 0037 Conf i dent i al ) .
122
09. 030 ( LR_01_121013_0028- 0037 Conf i dent i al ) .
123
Depar t ment of Heal t h, Dur ess/ Secur i t y Escor t Syst emPol i cy and Pr ocedur e
No. 12. 300 ( LR_01_121013_0038- 0045 Conf i dent i al ) .
124

r esponse t i me f or st af f t o r ender ai d was del ayed. Fur t her mor e,
t her e ar e r epor t s t hat t he PMTs f ai l t o t r ansmi t t he cor r ect
l ocat i on of t he code 200, t her eby af f ect i ng emer gency r esponse
t i mes, or f ai l ur e of st af f t o use t he PMT dur i ng a code 200.
125

Last l y, i n Mar ch 2013, HI OSH i ssued a ci t at i on wi t h a penal t y of
$1, 200 t o t he Hospi t al f or vi ol at i ng 12- 60- 2( a) ( 3) , Hawai i
Admi ni st r at i ve Rul es, due t o t he l ack of management
account abi l i t y t o ensur e t hat each and ever y empl oyee checks hi s
or her PMT weekl y t o make sur e t hat i t i s i n wor ki ng and
f unct i onal condi t i on.
126
The I nvest i gat i ve Commi t t ee st r ongl y
ur ges t he Hospi t al t o i mmedi at el y addr ess any i ssues wi t h t he
PMTs, i ncl udi ng upgr adi ng t he t echnol ogy i f necessar y.

c. Insufficient Fencing Around the Hospital Campus

Dur i ng t he I nvest i gat i ve Commi t t ee' s si t e vi si t of t he
Hospi t al i n J une 2014, i t obser ved t hat onl y uni t s F and H and
t he St at e Oper at ed Speci al i zed Resi dent i al Pr ogr am, commonl y
r ef er r ed t o as t he cot t ages, wer e f enced, but t he ot her uni t s as
wel l as t he Tr eat ment Mal l t hat accommodat e pat i ent s di d not
have f enced encl osur es. Whi l e t he I nvest i gat i ve Commi t t ee
r ecogni zes t hat t he Hospi t al i s not a cor r ect i onal f aci l i t y, i t
i s concer ned about t he absence of f enci ng ar ound t he per i met er
of t he Hospi t al campus. The Hospi t al ' s pat i ent census i s
pr edomi nat el y compr i sed of ment al heal t h f or ensi c pat i ent s, some
of whomhave been acqui t t ed of cr i mes by r eason of i nsani t y,
127

or ar e admi t t ed f or ment al heal t h eval uat i ons, or pur suant t o
t he Cl ar k per manent i nj unct i on.
128
As such, some of t hese
pat i ent s may pose a r i sk t o t he communi t y sur r oundi ng t he
Hospi t al , especi al l y st udent s and st af f at t he Wi ndwar d
Communi t y Col l ege, whi ch i s l ocat ed adj acent t o t he Hospi t al .
The I nvest i gat i ve Commi t t ee bel i eves t hat t he Hospi t al
admi ni st r at or s shoul d expl or e opt i ons and f undi ng mechani sms t o
i nst al l f enci ng ar ound t he per i met er of t he Hospi t al campus t o
ensur e saf et y f or t he sur r oundi ng communi t y.

d. Lack of Procedures to Notify the Police and Alert
the Public of a Patient Elopement

Al t hough t he Depar t ment of Heal t h r epor t s t hat t he number
of pat i ent el opement s f r omt he Hospi t al has decr eased f r om2010
t o 2013 due t o i t s i mpr oved pol i ci es and pr ocedur es and st af f
125
Depar t ment of Heal t h, Hospi t al Execut i ve Meet i ng Mi nut es ( LR_28_0622- 0626) .
126
Depar t ment of Heal t h, Document s Rel at ed t o HI OSH I nspect i on No. 316267160
( LR_20_0001- 0010 Conf i dent i al ) .
127
See, 704- 411( 1) ( a) , HRS.
128
Cl ar k v. St at e of Hawai i , St i pul at i on f or Amended Per manent I nj unct i on;
Or der , No. CV 99- 00885 DAE/ BMK ( 2003) .

di l i gence,
129
t he I nvest i gat i ve Commi t t ee i s concer ned t hat t he
Hospi t al l acks speci f i c pr ocedur es t o not i f y t he pol i ce and
al er t t he publ i c when a pat i ent escapes or el opes f r omt he
Hospi t al . The Hospi t al def i nes el opement s as an event f or any
l engt h of t i me i n whi ch a pat i ent l eaves t he f aci l i t y gr ounds or
l eaves f r oma communi t y out i ng wi t hout aut hor i zat i on and wi t hout
not i f yi ng t he st af f of an i nt ent i on t o do so.
130

i mpr oved pol i ci es and pr ocedur es f ai l t o pr escr i be who i s
r esponsi bl e f or gi vi ng not i ce and when t he pol i ce shoul d be
not i f i ed of a pat i ent el opement f r omt he Hospi t al . The
est abl i shed pr ocedur es f or pat i ent el opement s f r omt he Hospi t al
onl y i ndi cat e t hat t he pol i ce shoul d be not i f i ed or 911 be
cal l ed when a pat i ent i s agi t at ed and r ef usi ng ver bal
r edi r ect i on by st af f t o r et ur n t o t he Hospi t al .
131
The ext er nal
not i f i cat i on pr ocedur es i ncl ude cal l i ng t he pol i ce wi t h
pr ocedur es f or t he Nur si ng Super vi sor t o pr ovi de i nf or mat i on t o
t he r espondi ng pol i ce of f i cer ,
132
but do not i ndi cat e when t he
pol i ce shoul d be cal l ed. Whi l e t he I nvest i gat i ve Commi t t ee
not es t hat pat i ent el opement s may onl y be f or a shor t t i me, i t
bel i eves t hat t he pol i ce coul d f ur t her assi st t he Hospi t al ' s
sear ch ef f or t s t her eby r educi ng t he amount of t i me t hat a
pat i ent i s away f r omt he Hospi t al gr ounds.

Whi l e t her e ar e pr ocedur es t o not i f y Hospi t al
admi ni st r at or s, pat i ent f ami l y or si gni f i cant ot her s, case
management wor ker s, and soci al wor ker s, t her e ar e no pr ocedur es
t o not i f y or al er t t he publ i c, especi al l y t he st udent s and st af f
at Wi ndwar d Communi t y Col l ege, of a pat i ent el opement f r omt he
Hospi t al . The Wi ndwar d Communi t y Col l ege campus i s adj acent t o
t he Hospi t al campus wi t h onl y a pr i vat e r oad separ at i ng t he t wo
pr oper t i es. Wi t hout a f ence ar ound t he per i met er of t he
Hospi t al campus, i t i s possi bl e f or a Hospi t al pat i ent t o wander
ont o campus; i f t he pat i ent i s gone f r omt he Hospi t al l ong
enough, t he pat i ent may be abl e t o wander i nt o t he sur r oundi ng
communi t y, i ncl udi ng t he r esi dent i al nei ghbor hoods and publ i c
par k. I n l i ght of t he Hospi t al ' s f or ensi c ment al heal t h pat i ent
census, t he I nvest i gat i ve Commi t t ee bel i eves t hat t he Hospi t al
has an absol ut e r esponsi bi l i t y and dut y of car e t o t he
sur r oundi ng communi t y i n addi t i on t o i t s pat i ent s and st af f .
Accor di ngl y, t he Hospi t al shoul d devel op and i mpl ement
129
Depar t ment of Heal t h, Dat a on t he Number of El opement s Over t he Year s
( LR_01_020714_0065- 0066 - Conf i dent i al ) .
130
Pr ocedur e No. 19. 520 ( LR_01_020714_0068- 0082 - Conf i dent i al ) .
131
132

pr ocedur es t o not i f y t he publ i c, especi al l y Wi ndwar d Communi t y
Col l ege, of a pat i ent el opement t o expedi t e t he sear ch ef f or t s
and ensur e communi t y saf et y.

C. CHALLENGES IN PROVIDING EFFICIENT AND EFFECTIVE HUMAN
RESOURCES PRACTICES

S. R. No. 3 r equest ed t he I nvest i gat i ve Commi t t ee t o
i nvest i gat e al l egat i ons of Hospi t al admi ni st r at i ve and
empl oyment i mpr opr i et i es. The I nvest i gat i ve Commi t t ee f i nds
t hat al l eged i mpr opr i et i es, i ncl udi ng f avor i t i sm, nepot i sm, and
conf l i ct s of i nt er est , st emf r omi nef f i ci ent and i nef f ect i ve
human r esour ces pr act i ces.

Human r esour ces has been a per si st ent chal l enge f or t he
Hospi t al . One of t he ar eas of concer n t hat t he Hospi t al needed
t o addr ess under t he 1991 f eder al set t l ement agr eement and
subsequent r el at ed st i pul at ed or der s and r emedi al pl ans was t he
empl oyment and depl oyment of addi t i onal st af f .

I n 2012, t he Gover nor ' s Speci al Act i on Teamf ound t hat t he
exi st i ng al l ocat i on of human r esour ces i mpedes maxi mal ef f i ci ent
use and t hat t her e ar e per si st ent st af f vacanci es t hat i ncr ease
over t i me cost s and compr omi se t he accompl i shment s of t he
Hospi t al ' s pr ogr ammat i c goal s.
133

Despi t e f eder al and st at e i nt er vent i on, t he Hospi t al
cont i nues t o f ace chal l enges i n f i l l i ng vacant posi t i ons,
obt ai ni ng addi t i onal st af f i n t he most cost - ef f ect i ve manner ,
and mai nt ai ni ng empl oyee mor al e. The I nvest i gat i ve Commi t t ee
f i nds t hat t he Hospi t al ' s i nef f i ci ent and i nef f ect i ve human
r esour ces pr act i ces r esul t i n i nef f i ci enci es and hi gh per sonnel
cost s. The I nvest i gat i ve Commi t t ee f ur t her f i nds t hat t he l ack
of l eader shi p i n managi ng and ensur i ng f ai r and t r anspar ent
Hospi t al human r esour ces pr act i ces cont r i but es t o l ow empl oyee
mor al e, er odes empl oyees' t r ust of and conf i dence i n Hospi t al
admi ni st r at or s and super vi sor s, and causes empl oyees t o f ear
r et al i at i on by Hospi t al admi ni st r at or s and super vi sor s.

133
Depar t ment of Heal t h, Special Action Team Report to the Governor on

1. Inefficient Hiring Practices Contribute to Persistent
Vacancies

The Hospi t al has an over al l vacancy r at e of 12%,
134
whi ch i s
appr oxi mat el y 60 di r ect and non- di r ect car e posi t i ons.
135
The
vacancy r at e i s 8%f or di r ect car e posi t i ons.
136
Di r ect car e
posi t i ons ar e t hose di r ect l y assi gned t o pat i ent uni t s whi l e
suppor t posi t i ons ar e commonl y r ef er r ed t o as non- di r ect car e
posi t i ons. Accor di ng t o t he For mer Act i ng Hospi t al
Admi ni st r at or , Wi l l i amEl l i ot t , t he Hospi t al has t he
aut hor i zat i on t o f i l l t hese vacant posi t i ons and i s const ant l y
i n t he pr ocess of hi r i ng st af f .
137
Per si st ent vacant posi t i ons
i ncur gr eat er per sonnel expenses f or over t i me or t empor ar y
empl oyee agency st af f i ng and l ead t o concer ns r egar di ng pat i ent
car e. Accor di ngl y, i t i s vi t al f or t he Hospi t al t o st r engt hen
i t s abi l i t y t o r ecr ui t st af f . However , t he I nvest i gat i ve
Commi t t ee f i nds t hat t he Hospi t al l acks ef f i ci ent hi r i ng
pr ocesses and pr ocedur es t o ensur e t hat vacanci es ar e f i l l ed i n
an expedi t i ous and f ai r manner .

a. Inefficient Recruitment and Hiring Process

Mr . El l i ot t t est i f i ed t hat a st udy conduct ed year s ago
f ound t hat i t t ook t he St at e appr oxi mat el y 66 wor ki ng days,
appr oxi mat el y over t hr ee mont hs, t o f i l l a vacant posi t i on.
138

The hi r i ng pr ocess at t he Hospi t al cur r ent l y t akes l onger t han
66 wor ki ng days. The I nvest i gat i ve Commi t t ee f i nds t hat one of
t he r easons t he Hospi t al i s unabl e t o f i l l i t s vacant posi t i ons
i s due t o an i nef f i ci ent r ecr ui t ment and hi r i ng pr ocess, whi ch
r equi r es numer ous st eps bef or e appl i cant s ar e hi r ed. Fi gur e 3. 4
i l l ust r at es t he mul t i pl e st eps r equi r ed t o f i l l a vacant
posi t i on. The I nvest i gat i ve Commi t t ee not es t hat Fi gur e 3. 4
hi ghl i ght s t he mai n st eps i n t he pr ocess and does not i ndi cat e
any separ at e st eps speci f i c t o a ci vi l ser vi ce, non- ci vi l
ser vi ce, or exempt posi t i on.

134
on J anuar y 7, 2014 ( LR_01_0033- 0061) .
135
Test i mony of Wi l l i amEl l i ot t , Apr i l 9, 2014.
136
on J anuar y 7, 2014 ( LR_01_0033- 0061) .
137
138

Figure 3.4
Simplified Hiring Process to Fill a Hospital Vacant Position

139

Hospital
(Vacancy)
Supervisor prepares a Request to Fill Form and routes to Business Office for review
Associate Administrator of Administrative and Support Services receives request from
Business Ofice for review and approval and submits to Personnel Office
Personnel Office processes request and prepares forms to submit to the Adult Mental
Health Division (AMHD) for review
Department
of Health
(AMHD)
AMHD reviews request form and if no revisions are necessary, forwards request to the
Administrative Services Office (ASO)
ASO reviews request form and if no revisions are necessary, forwards to the Human
Resources Office (HRO)
Department
of Health
(HRO)
HRO opens an Internal Vacancy Announcement, sends Announcement to Department
programs via email, and posts on the Department's website for two weeks
HRO screens internal applications after recruitment closes and requests an external list of
applicants from the Department of Human Resources Development (DHRD) if there are no
internal applicants
Hospital
(Personnel)
Personnel receives a list of eligible applicants and records receipt of the list on a vacancy
report
Personnel assembles interview packets and sends to position's supervisor
Hospital
(Interview)
Supervisor receives packets and assembles interview panels to conduct interviews
All individuals on the internal list must be interviewed and an attempt must be made to
contact everyone on the external list
Personnel review packets and enter results into vacancy report
Department
of Health
(HRO)
HRO receives the packets for review
HRO determines whether a selection is valid then notifies the Hospital to make a conditional
offer
If no selection is made, then HRO will request another eligible list from DHRD
Hospital
(Offer &
Hire)
Hospital makes a conditional offer to the applicant
If applicant accepts offer, then applicant must clear background check and medical
requirements
Start date is set and applicant is placed into position
Under Fi gur e 3. 4, a r equest t o f i l l a vacant posi t i on goes
t hr ough f i ve di f f er ent i ndi vi dual s or of f i ces at t he Hospi t al or
t he Depar t ment of Heal t h f or r evi ew and appr oval bef or e a
vacancy announcement i s post ed and a l i st of el i gi bl e candi dat es
t o f i l l t he posi t i on i s cr eat ed. Once a l i st of candi dat es i s
est abl i shed, t he i nt er vi ew pr ocess needs t o be compl et ed and
appr oval f r omt he Depar t ment of Heal t h' s Human Resour ces Of f i ce
must be gi ven bef or e t he Hospi t al i s abl e t o make a condi t i onal
of f er t o an appl i cant . The I nvest i gat i ve Commi t t ee not es t hat
del ays can happen at each of t he mul t i pl e st eps i n t he
r ecr ui t i ng and hi r i ng pr ocess t hat can r esul t i n f ur t her del ays
i n r ecr ui t i ng and hi r i ng Hospi t al st af f . Whi l e t he Hospi t al may
vi ew t hi s pr ocess as a met hod t o ensur e t hat empl oyees ar e
car ef ul l y vet t ed and sel ect ed f or a posi t i on, t he I nvest i gat i ve
Commi t t ee f i nds t hat t he exi st i ng r ecr ui t i ng and hi r i ng pr ocess
can be st r eaml i ned wi t hout compr omi si ng i nt egr i t y and f ai r ness.

Despi t e t hi s i nef f i ci ent pr ocess, t he I nvest i gat i ve
Commi t t ee coul d not det er mi ne i f anyt hi ng has been done t o
i mpr ove t he r ecr ui t ment and hi r i ng pr ocess. I n 2012, t he
Gover nor ' s Speci al Act i on Team
140
r ecommended t hat t he Depar t ment
of Heal t h' s Human Resour ces Of f i ce and Admi ni st r at i ve Ser vi ces
Of f i ce, Depar t ment of Human Resour ces Devel opment , and ot her s
wor k t oget her t o pr i or i t i ze r ecr ui t ment and obt ai n
admi ni st r at i ve appr oval f or posi t i ons t hat may i mpact t he
pat i ent census and pr ovi de di ver si on ser vi ces. The Speci al
Act i on Teamal so r ecommended t hat t he Depar t ment of Heal t h
assi st t he Depar t ment of Human Resour ces Devel opment i n
scr eeni ng Hospi t al appl i cat i ons. However , Mr . El l i ot t i nf or med
t he I nvest i gat i ve Commi t t ee t hat t hese r ecommendat i ons di d not
pr oduce any addi t i onal Hospi t al empl oyees.
141
Fi gur e 3. 5
i ndi cat es t he number of hi r es t he Hospi t al made i n 2013.

139
Based on t he mat er i al submi t t ed by t he Depar t ment of Heal t h of a f l owchar t
i ndi cat i ng t he hi r i ng pr ocess, hi r i ng aut hor i t y, and l ocat i ons of each poi nt
of t he hi r i ng pr ocess ( LR_12_0001- 0012 and LR_13_0001- 0012) .
140
Depar t ment of Heal t h, Special Action Team Report to the Governor on
141

Figure 3.5
Hiring of Direct Care Positions in 2013

Licensed Practical
Nurse (LPN)
Para Medical
Assistant (PMA)
Psychiatric
Technician (PT)
Registered Nurse
(RN)
Eligible 35 455 98 148
Interviewed 5 96 65 52
Hired 0 5 6 8
Separated 1 4 14 5

142

The number of hi r es i n 2013 had a mi ni mal i mpact on t he
Hospi t al ' s vacancy r at e. Accor di ngl y, t he I nvest i gat i ve
Commi t t ee st r ongl y bel i eves t hat t he Hospi t al Admi ni st r at i on
must make a st r onger ef f or t t o i mpr ove and st r eaml i ne t he
r ecr ui t ment and hi r i ng pr ocess.

The I nvest i gat i ve Commi t t ee f ur t her f i nds t hat t he
i nef f i ci ent r ecr ui t i ng and hi r i ng pr ocess cr eat es oppor t uni t i es
f or i ndi vi dual s t o obt ai n empl oyment at t he Hospi t al t hr ough
t empor ar y empl oyment agenci es t her eby bypassi ng t he est abl i shed
hi r i ng pr ocess. The Hospi t al has 13- week cont r act s f or
addi t i onal st af f f r ompr i vat e sect or t empor ar y empl oyment
agenci es t o meet i t s appr opr i at e st af f i ng needs. The Di r ect or
of Nur si ng, Leona Guest ,
143
and Associ at e Chi ef Nur se, Emma
Evans,
144
t est i f i ed t hat , on behal f of t he Hospi t al , t hey have
pr ovi ded r ef er r al s t o t hese t empor ar y empl oyment agenci es f or
t hese r ef er r ed i ndi vi dual s t o wor k at t he Hospi t al . As a
r esul t , i ndi vi dual s who ar e r ef er r ed by t he Hospi t al ar e
pr ovi ded 13- week cont r act s t o wor k at t he Hospi t al wi t hout
engagi ng i n t he Hospi t al ' s f or mal r ecr ui t ment and hi r i ng
pr ocess.

Al t hough t he I nvest i gat i ve Commi t t ee r ecogni zes t he need
f or agency wor ker s t o meet st af f i ng demands, i t i s concer ned
t hat cont r act s wi t h agency wor ker s wi t h r ef er r al s f r omt he
Hospi t al can cr eat e t he appear ance of f avor i t i smand have a
negat i ve i mpact on empl oyee mor al e, especi al l y when such
i ndi vi dual s ar e r el at i ves or f r i ends of Hospi t al admi ni st r at or s
or super vi sor s or ar e i ndi vi dual s who wer e not pr evi ousl y hi r ed
by t he Hospi t al f or a per manent posi t i on t hr ough t he f or mal
hi r i ng pr ocess. Ms. Guest t est i f i ed t hat she woul d have
di scour aged her daught er f r omwor ki ng at t he hospi t al vi a a
142
on J anuar y 7, 2014 ( LR_01_0033- 0061) .
143
Test i mony of Leona Guest , J une 18, 2014.
144
Test i mony of Emma Evans, Apr i l 30, 2014.

t empor ar y empl oyment agency i f she knew t hat t hi s r ef er r al woul d
cause st af f t o make al l egat i ons of f avor i t i sm.
145

Fur t her mor e, t he I nvest i gat i ve Commi t t ee f i nds t hat t he
f or mal r ecr ui t ment and hi r i ng pr ocess al l ows t empor ar y
empl oyment agency wor ker s t o have an advant age i n obt ai ni ng a
per manent posi t i on at t he Hospi t al . The Depar t ment of Heal t h
engages i n an i nt er nal r ecr ui t ment pr ocess, and agency st af f
have access t o t hese vacancy post i ngs.
146
I n addi t i on, si nce
t hese agency wor ker s r ecei ve t r ai ni ng whi l e per f or mi ng t hei r 13-
week cont r act s, t hey gai n Hospi t al wor k exper i ence.
147
As a
r esul t , agency wor ker s have an advant age over any el i gi bl e
candi dat es wi t hout wor k exper i ence at t he Hospi t al .

Whi l e t he I nvest i gat i ve Commi t t ee r ecogni zes t hat agency
wor ker s st i l l need t o be i nt er vi ewed and appr oved f or hi r e, i t
i s concer ned t hat t he hi r i ng of cer t ai n agency wor ker s f or a
per manent posi t i on at t he Hospi t al may cr eat e t he appear ance of
f avor i t i sm, especi al l y i f t hose agency wor ker s wer e not
pr evi ousl y hi r ed f or a Hospi t al per manent posi t i on or t hei r
names ar e r epeat edl y gi ven t o t he t empor ar y empl oyment agenci es
t o wor k at t he Hospi t al on a 13- week cont r act . Thi s can
exacer bat e l ow empl oyee mor al e.

b. Lack of Internal Policies to Ensure a Fair Hiring
Process

The I nvest i gat i ve Commi t t ee f i nds t hat t her e ar e a number
of empl oyees who ar e r el at ed t o each ot her because t her e ar e no
i nt er nal pol i ci es r egar di ng t he hi r i ng of r el at i ves of empl oyees
at t he Hospi t al . Fi gur es 3. 6 and 3. 7 i l l ust r at e t he number of
Hospi t al empl oyees or agency wor ker s r el at ed t o t he Associ at e
Chi ef Nur se and Di r ect or of Nur si ng.

145
146
147

Figure 3.6
Relatives of the Associate Chief Nurse Employed at the Hospital

148
and Emma Evans
149

Figure 3.7
Relatives of the Director of Nursing Employed at the Hospital

150

148
Depar t ment of Heal t h, Char t I dent i f yi ng St af f Member s who ar e Rel at ed t o
Each Ot her ( LR_33_0001- 0007 Conf i dent i al )
149
150
Depar t ment of Heal t h, Char t I dent i f yi ng St af f Member s who ar e Rel at ed t o
Each Ot her ( LR_33_0001- 0007 Conf i dent i al )
Emma
Evans
Sister-in-
Law
Sister-in-
Law
Sister-in-
Law
Sister
Sister
Daughter
Leona
Guest
Relative
Niece
Daughter
(Agency
Worker)
Daughter
Son

Ther e ar e a number of empl oyees, l i ke Ms. Evans and Ms.
Guest , who have mor e t han one r el at i ve wor ki ng at t he Hospi t al .
However , t he I nvest i gat i ve Commi t t ee not es t hat Ms. Evans and
Ms. Guest ar e Hospi t al admi ni st r at or s wi t h f i ve or mor e
r el at i ves wor ki ng at t he Hospi t al , whi ch cal l s i nt o quest i on t he
appr opr i at eness and necessi t y of havi ng t hat many r el at ed
i ndi vi dual s on t he Hospi t al payr ol l . The I nvest i gat i ve
Commi t t ee r ecogni zes t hat empl oyi ng r el at i ves on st af f may not
af f ect wor k per f or mance and not es t hat nepot i smi s not a
vi ol at i on of st at e l aw or t he St at e' s Code of Et hi cs. However ,
wi t hout i nt er nal pol i ci es r egar di ng t he empl oyment of r el at i ves
on st af f , t he I nvest i gat i ve Commi t t ee f i nds t hat empl oyi ng
r el at i ves on st af f l eads t o al l egat i ons of f avor i t i smand
negat i vel y i mpact s empl oyee mor al e, whi ch can, i n t ur n, i mpact
wor k per f or mance.

Fur t her mor e, t he I nvest i gat i ve Commi t t ee i s concer ned about
t he l ack of pr ocedur es t o ensur e t hat t he i nt er vi ew pr ocess i s
f r ee f r omconf l i ct s of i nt er est or even t he appear ance of
conf l i ct s of i nt er est . Mr . El l i ot t t est i f i ed t hat he woul d
expect st af f member s t o r ecuse t hemsel ves f r ompar t i ci pat i ng on
panel s t hat wi l l be i nt er vi ewi ng appl i cant s r el at ed t o t hem.
151

However , t her e ar e no i nt er nal pol i ci es or pr ocedur es t o ensur e
t hat st af f do not par t i ci pat e i n i nt er vi ewi ng t hei r r el at i ves
and, as a r esul t , i t i s possi bl e t hat a r el at i ve of an appl i cant
coul d ser ve on t hat appl i cant ' s i nt er vi ew panel .

The I nvest i gat i ve Commi t t ee i s al so deepl y concer ned about
t he number of super vi sor s or admi ni st r at or s who have r el at i ves
on st af f at t he Hospi t al and how t hei r posi t i ons may i nf l uence
t he i nt er vi ew panel ' s r ecommendat i on f or hi r e. For exampl e, Ms.
Evans, who i s t he Associ at e Chi ef Nur se i n char ge of t he Nur si ng
Of f i ce, t est i f i ed t hat she not i f i ed cer t ai n i ndi vi dual s who
ser ved on an appl i cant ' s i nt er vi ew panel t hat she was r el at ed t o
t he appl i cant .
152
Si nce Ms. Evans ser ves i n an admi ni st r at i ve
posi t i on, t he I nvest i gat i ve Commi t t ee i s concer ned t hat her
act i ons coul d be consi der ed as usi ng or at t empt i ng t o use her
of f i ci al posi t i on t o secur e or gr ant unwar r ant ed advant ages or
t r eat ment f or her sel f or ot her s, whi ch i s a vi ol at i on of t he
St at e' s Code of Et hi cs.
153
Wi t hout ef f ect i ve mechani sms i n pl ace
t o pr event f avor i t i sm, conf l i ct s of i nt er est , and undue
i nf l uence or t he appear ance t her eof , t he i nt egr i t y and f ai r ness
of t he exi st i ng hi r i ng pr ocess i s compr omi sed.

151
152
153
See, 84- 13, HRS.

2. Lack of Control of Overtime and Sick Leave Costs the
State Money

The Hospi t al uses t he J ohnson Behavi or al Model
154
as t he
est abl i shed met hodol ogy t o assess a pat i ent ' s cl i ni cal need
( e. g. , assess whet her a pat i ent r equi r es a wheel chai r or
i dent i f y any chal l engi ng behavi or s of t he pat i ent ) and i dent i f y
appr opr i at e nur se st af f i ng r at i os t o pr ovi de appr opr i at e car e
f or pat i ent s. I n J une 2013,
155
t he Hospi t al adj ust ed i t s nur se
st af f i ng mat r i x t o i ncl ude t he number of pat i ent s l ocat ed i n any
pat i ent car e ar ea due t o t he Hospi t al ' s gr owi ng pat i ent census.
As a r esul t , t he nur se st af f i ng l evel s of each uni t ar e adj ust ed
dai l y, and t he assi st ance of addi t i onal nur se st af f i s r out i nel y
r equest ed t o meet each pat i ent ' s car e needs and t he number of
pat i ent s of each uni t . Addi t i onal nur se st af f may be obt ai ned
f r omHospi t al nur se st af f wor ki ng over t i me shi f t s i n addi t i on t o
t hei r r egul ar l y schedul ed shi f t s or t hr ough cont r act ed wor ker s
f r omt empor ar y empl oyee ser vi ce agenci es.

Each Uni t Nur se Manager i s r esponsi bl e f or cont act i ng a
Nur si ng Shi f t Super vi sor i n t he Nur si ng Of f i ce t o pr ovi de a
number of any addi t i onal st af f t hat i s needed f or each shi f t t o
achi eve t he appr opr i at e nur se st af f i ng r at i os f or t hei r
r espect i ve uni t s.
156
The schedul i ng cl er ks i n t he Nur si ng Of f i ce
mai nt ai n t he shi f t schedul es of t he nur se st af f
157
and ar e
r esponsi bl e f or cont act i ng and obt ai ni ng any addi t i onal st af f t o
f i l l shi f t s t hat ar e open due t o nur se st af f who ar e out on si ck
l eave or vacat i on or shi f t s t hat ar e necessar y t o meet t he nur se
st af f i ng mat r i x f or a par t i cul ar uni t .
158

Over t i me shi f t s ar e gener al l y assi gned on a r ot at i ng
basi s.
159
Ot her f act or s af f ect i ng t he assi gnment of over t i me
i ncl ude uni t assi gnment s, t er ms i n col l ect i ve bar gai ni ng
agr eement s, and whet her t he nur se st af f i s empl oyed by t he St at e
or under cont r act wi t h t he t empor ar y empl oyee ser vi ce agency.
160

Thi s syst emof assi gni ng and usi ng over t i me i s i nt ended t o be
f ai r and i n accor dance wi t h t er ms of col l ect i ve bar gai ni ng.
154
on J anuar y 7, 2014 ( LR_01_0033- 0061) .
155
Response dat ed J anuar y 15, 2014 f r omDepar t ment of Heal t h t o t he
I nvest i gat i ve Commi t t ee t o t he wr i t t en quest i ons and r equest f or i nf or mat i on
( LR_01_011514_0049- 0052 - Conf i dent i al ) .
156
157
Posi t i on Descr i pt i ons f or Of f i ce Assi st ant I I I ( Schedul i ng Cl er ks)
( MAF_043014_07_0002- 0026) .
158
Test i mony of Debr a Ono, May 14, 2014.
159
160
Test i mony of Debr a Ono, May 14, 2014; Test i mony of Leona Gust , J une 18,
2014; and Test i mony of Wi l l i amEl l i ot t , J une 18, 2014.

However , t he I nvest i gat i ve Commi t t ee f i nds t hat t he Hospi t al
l acks mechani sms t o moni t or and cont r ol t he use of over t i me and
si ck l eave benef i t s, whi ch r esul t s i n i nef f i ci enci es i n
assi gni ng over t i me and hi gh per sonnel over t i me cost s f or t he
St at e; cont r i but es t o l ow empl oyee mor al e; and r ai ses concer ns
r egar di ng t he qual i t y of car e r ecei ved by t he pat i ent s.

a. Lack of a Standardized System to Assign Overtime

The I nvest i gat i ve Commi t t ee f i nds t hat t he pr ocedur es i n
assi gni ng over t i me ar e not st andar di zed. Debr a Ono, a
schedul i ng cl er k at t he Hospi t al , t est i f i ed t hat when assi gni ng
over t i me shi f t s t o nur se st af f , she r ef er s t o t he mast er
schedul e t o det er mi ne who i s avai l abl e accor di ng t o t he r ot at i ng
syst em, cr eat es a l i st of names of avai l abl e st af f , t hen
pr oceeds t o cal l t hese st af f member s unt i l she i s abl e t o f i l l
al l open shi f t sl ot s.
161
She expl ai ned t hat she assi gns over t i me
shi f t s accor di ng t o t he i nst r uct i ons and t r ai ni ng she r ecei ved
by her cowor ker s because a wr i t t en st andar di zed pr ocedur es
manual does not exi st .
162
As a r esul t , Ms. Ono t est i f i ed t hat
each of t he si x schedul i ng cl er ks who wor k at t he Nur si ng Of f i ce
assi gns over t i me shi f t s di f f er ent l y dependi ng on t he t r ai ni ng
r ecei ved f r omcowor ker s.
163
Al t hough t he Di r ect or of Nur si ng,
Leona Guest ,
164
and Associ at e Chi ef Nur se, Emma Evans,
165

t est i f i ed t hat wr i t t en pr ocedur es f or assi gni ng over t i me ar e
par t of t he Nur si ng Of f i ce' s st andar d oper at i ng pr ocedur es, t he
I nvest i gat i ve Commi t t ee bel i eves t hat t hese st andar d oper at i ng
pr ocedur es ar e not bei ng wi del y and consi st ent l y i mpl ement ed by
t he schedul i ng cl er ks i n t he Nur si ng Of f i ce.

The I nvest i gat i ve Commi t t ee f i nds t hat t he absence of a
st andar di zed syst emt o assi gn over t i me shi f t s i ncr eases t he r i sk
of assi gnment di scr epanci es and may r esul t i n cer t ai n st af f
r ecei vi ng mor e over t i me shi f t s t han ot her s or over t i me shi f t s
t hat appear out of r ot at i on. As a r esul t , st af f may f i l e
compl ai nt s t hat t hey wer e bypassed f or an over t i me shi f t
oppor t uni t y. I f a di scr epancy i s f ound, t he Hospi t al r out i nel y
r esponds by pr ovi di ng t he st af f member t wo oppor t uni t i es f or
over t i me t he next t i me t he empl oyee' s name i s next on t he
r ot at i on.
166
However , over t i me shi f t assi gnment di scr epanci es or
compl ai nt s ar e compounded by t he appear ance of f avor i t i sm. Ms.
Evans t est i f i ed t hat t her e i s a per cept i on among st af f t hat t he
161
162
163
164
165
166

Nur si ng Of f i ce has f avor i t es when assi gni ng over t i me.
167
Whi l e
assi gnment di scr epanci es, i f any, may be cur ed by pr ovi di ng an
empl oyee wi t h t wo addi t i onal oppor t uni t i es f or over t i me, t he
I nvest i gat i ve Commi t t ee f i nds t hat t he appear ance or per cept i on
of f avor i t i smi s not as easi l y r esol ved and has l ong- t er m
ef f ect s on nur se st af f mor al e. Ther ef or e, i t i s i ncumbent on
t he Hospi t al t o i mpl ement a st andar di zed syst emf or assi gni ng
over t i me so t hat t he pr ocess i s f ai r and t r anspar ent .

The I nvest i gat i ve Commi t t ee not es t hat f or mer Act i ng
Hospi t al Admi ni st r at or , Wi l l i amEl l i ot t , t est i f i ed i n Apr i l
2014, t hat f or t he past ni ne mont hs, t he Hospi t al was i n t he
pr ocess of pr ocur i ng a comput er schedul i ng syst emt o assi st wi t h
assi gni ng over t i me shi f t s and cont r ol l i ng f avor i t i sm.
168
Named
Kr onos, t he schedul i ng syst emi s expect ed t o al i gn wi t h
col l ect i ve bar gai ni ng r equi r ement s, adher e t o Hospi t al pol i ci es
and pr ocedur es, and meet st af f i ng demands and schedul ed changes
t o qui ckl y i dent i f y qual i f i ed subst i t ut es, aut omat i cal l y not i f y
t hem, and f i l l t he shi f t openi ng.
169
The I nvest i gat i ve Commi t t ee
bel i eves t hat t hi s comput er i zed schedul i ng syst emwi l l i ncr ease
ef f i ci ency and assi st i n mi ni mi zi ng t he per cept i on of
f avor i t i sm. The I nvest i gat i ve Commi t t ee ur ges t he Hospi t al t o
expedi t e i t s pl ans t o i nst al l t he Kr onos syst em.

b. No Limits on the Number of Overtime Shifts an
Employee May Perform

Over t i me i s consi der ed a necessar y measur e t o meet
appr opr i at e nur se st af f i ng r at i os f or each uni t at t he Hospi t al .
However , t he I nvest i gat i ve Commi t t ee f i nds t hat t her e ar e a
number of empl oyees who have per f or med amount s of over t i me hour s
t hat si gni f i cant l y exceed a r egul ar 40- hour wor k week because
t her e ar e no l i mi t s t o t he number of over t i me shi f t s an empl oyee
may per f or m. Fi gur e 3. 8 i ndi cat es t he combi ned t ot al number of
over t i me hour s and amount s of t he t op si x over t i me Hospi t al
empl oyee ear ner s.

167
168
169
Response dat ed Febr uar y 7, 2014 f r omt he Depar t ment of Heal t h t o t he
I nvest i gat i ve Commi t t ee t o t he wr i t t en quest i ons and r equest f or i nf or mat i on
( LR_01_020714_0001- 0005 - Conf i dent i al ) .

Figure 3.8
Combined Totals of the Top Six Overtime Earners for FY2013 and
2014

FY2014 (Up to January 31, 2014)
Total Overtime Hours Total Overtime Amounts
4,475.50 $159,977.56

FY2013
Total Overtime Hours Total Overtime Amounts
7,396.80 $202,837.56

170

Per mi t t i ng st af f t o accumul at e i ndef i ni t e amount s of
over t i me has a f i scal i mpact on t he Hospi t al as wel l as t he
St at e. The Hospi t al ' s per sonnel budget i s appr oxi mat el y $35
mi l l i on per year wi t h an addi t i onal $3 mi l l i on f or over t i me
cost s.
171
For FY2013, t he combi ned t ot al over t i me cost s f or t he
si x t op over t i me ear ner s i l l ust r at ed i n Fi gur e 3. 8 was
appr oxi mat el y 6. 7%of t he Hospi t al ' s $3 mi l l i on over t i me budget .
Unl i mi t ed over t i me shi f t s cr eat es di f f i cul t i es f or t he Hospi t al
t o accur at el y budget per sonnel cost s, especi al l y when t he
Hospi t al pat i ent census r egul ar l y exceeds t he budget ed census of
168 pat i ent s.

Over t i me pay i s cal cul at ed at 1. 5 t i mes t he empl oyee' s base
r at e pay.
172
Thi s cr eat es a shor t - t er mf i nanci al i ncent i ve f or
st af f t o wor k over t i me shi f t s because empl oyees ar e abl e t o
suppl ement t hei r base sal ar i es. Under Fi gur e 3. 8, t he si x t op
over t i me ear ner s f or FY2013 aver aged an appr oxi mat e 64- hour wor k
week, whi ch i s appr oxi mat el y 24 hour s i n addi t i on t o t hei r 40-
hour r egul ar l y schedul ed pai d wor k week.
173
Thus, some empl oyees
who accumul at e si gni f i cant amount s of over t i me hour s ar e abl e t o
doubl e t hei r sal ar y i ncome wi t h over t i me pay. Fur t her mor e,
accumul at i ng over t i me pay has a l ong- t er mef f ect i f t he empl oyee
was hi r ed by t he St at e pr i or t o J ul y 1, 2012, because over t i me
pay i s f act or ed i nt o t he empl oyee' s r et i r ement pensi on.
174
Thus,
t he I nvest i gat i ve Commi t t ee f i nds t hat over t i me cost s r esul t i n
hi gher cost s f or t he St at e, and t he Hospi t al needs t o i mpl ement
mechani sms t o cont r ol i t s over t i me cost s whi l e st i l l meet i ng i t s
st af f i ng demands.
170
Depar t ment of Heal t h, HSH Top Si x Over t i me Hour s ( LR_25_0001
171
Test i mony of Wi l l i amEl l i ot t , J une 18, 2014.
172
173
Cal cul at i ons based on f i gur es submi t t ed by t he Depar t ment of Heal t h, HSH
Top Si x Over t i me Hour s ( LR_25_0001 Conf i dent i al ) .
174
Over t i me i s i ncl uded i n r et i r ement compensat i on pur suant t o 88- 21. 5( a) ,
HRS, i f t he member became a member bef or e J ul y 1, 2012.

Fur t her mor e, t he I nvest i gat i ve Commi t t ee i s concer ned wi t h
how unl i mi t ed amount s of over t i me per f or med by st af f , especi al l y
back- t o- back shi f t s, af f ect t he st andar ds of pat i ent car e,
Hospi t al saf et y, and wor k per f or mance. Dur i ng a 12- mont h per i od
f r om2013 t o 2014, t he Hospi t al r epor t ed 173 empl oyees who
wor ked 16- hour shi f t s or l onger .
175
The Di r ect or of Nur si ng,
Leona Guest , t est i f i ed t hat t he Hospi t al does not have dat a t o
i ndi cat e whet her t her e i s a cor r el at i on bet ween over t i me and
wor k per f or mance.
176
Regar dl ess of t he l ack of dat a, t he
I nvest i gat i ve Commi t t ee bel i eves t hat st r onger pol i ci es shoul d
be devel oped and i mpl ement ed t o cont r ol t he amount of over t i me
t hat each empl oyee may per f or mt o mai nt ai n wor k per f or mance and
pat i ent car e st andar ds.

The Depar t ment of Heal t h' s Deput y Di r ect or of Behavi or al
Heal t h Admi ni st r at i on, Lynn Fal l i n, t est i f i ed t hat t he Hospi t al
has r ecent l y i mpl ement ed a " wel l ness cap" t hat l i mi t s empl oyees
t o 350 over t i me hour s per f i scal quar t er .
177
However , t he
I nvest i gat i ve Commi t t ee f i nds t hat t hi s " wel l ness cap" f ai l s t o
adequat el y cont r ol t he amount s of over t i me an empl oyee i s
al l owed t o accumul at e. A cap of 350 hour s per f i scal quar t er
means t hat an empl oyee coul d accumul at e up t o 1, 400 hour s of
over t i me per f i scal year . I f t hi s " wel l ness cap" was appl i ed t o
t he l i st of t he t op si x hi ghest over t i me ear ner s f or FY2013,
178

onl y t he t op t wo empl oyees on t hat l i st woul d be af f ect ed by
t hi s cap. Thus, t he I nvest i gat i ve Commi t t ee does not bel i eve
t hat t hi s " l i mi t at i on" subst ant i al l y i mpact s or cont r ol s t he
amount of over t i me, saves t he Hospi t al and St at e money, or
pr omot es wel l ness among st af f .

c. Opportunities for Employees to Abuse Sick Leave
and Overtime Benefits

Over t i me shi f t s become avai l abl e when t he nur se st af f i ng
r at i os r equi r e addi t i onal st af f t o car e f or a hi gh pat i ent
census, meet t he cl i ni cal needs of pat i ent s, or f i l l i n f or
empl oyees who ar e on si ck l eave or vacat i on. As st at e
empl oyees, each empl oyee ear ns 14 hour s of pai d si ck l eave per
mont h t hat can be accumul at ed. Fur t her mor e, empl oyees who ar e
ci vi l ser vant s or i ncl uded i n col l ect i ve bar gai ni ng wi l l ear n
175
Cal cul at i ons based on l i st submi t t ed by t he Depar t ment of Heal t h r egar di ng
empl oyees wor ki ng 16- hour shi f t s or l onger over t he l ast 12- mont hs
( LR_05_061814_0001- 0004) .
176
177
178
Depar t ment of Heal t h, HSH Top Si x Over t i me Hour s ( LR_25_0001

over t i me compensat i on f or shi f t s i n whi ch t hose empl oyees ar e
not schedul ed t o wor k.
179

The I nvest i gat i ve Commi t t ee f i nds t hat t he f i nanci al
i ncent i ves of over t i me combi ned wi t h t he empl oyee benef i t s of
pai d si ck l eave cr eat es an oppor t uni t y f or empl oyees t o abuse
t hese benef i t s f or f i nanci al gai n. When t he I nvest i gat i ve
Commi t t ee asked Ms. Guest whet her she f el t t hat t he over t i me
syst emi s bei ng abused, she answer ed, " Yes, absol ut el y. "
180

However , t he Hospi t al has done l i t t l e t o cont r ol t he r i sks of
over t i me and si ck l eave abuse.

Fi gur es 3. 9 t o 3. 11 i l l ust r at e di f f er ent ways empl oyees
coul d combi ne t he use of t hei r over t i me and pai d si ck l eave
benef i t s t o ear n mor e compensat i on and, i n some i nst ances, wor k
l ess t han a 40- hour wor k week. These scenar i os ar e based on
exampl es pr ovi ded and obser vat i ons made by Ms. Ono
181
and ar e not
i nt ended t o i mpl i cat e or r epr esent an act ual empl oyee. Pl ease
not e t hat " Reg. Shi f t " means a r egul ar schedul ed shi f t and " OT
Shi f t " means an over t i me shi f t .

Figure 3.9
Employee A Using a Combination of Overtime and Sick Leave

Employee A's Regular Work Schedule
Sunday Monday Tuesday Wednesday Thursday Friday Saturday

DAY OFF

REG. SHIFT

REG. SHIFT

REG. SHIFT

DAY OFF

REG. SHIFT

REG. SHIFT

Employee A's Amended Work Schedule

OT SHIFT

REG. SHIFT

SICK LEAVE

SICK LEAVE

OT SHIFT

REG. SHIFT

REG. SHIFT

Not e: Days shaded gr ay i ndi cat e days Empl oyee A i s not pr esent at wor k.

I n t he scenar i o i l l ust r at ed i n Fi gur e 3. 9, Empl oyee A' s
r egul ar wor k schedul e i s a 40- hour wor k week wi t h t wo days of f .
I f Empl oyee A t akes si ck l eave benef i t s dur i ng t wo r egul ar l y
schedul ed shi f t s and wor ks over t i me shi f t s dur i ng t wo r egul ar l y
schedul ed days of f , Empl oyee A wi l l st i l l per f or ma 40- hour wor k
179
180
181

week, but be compensat ed mor e due t o t he t wo over t i me shi f t s
per f or med t hat week.

Figure 3.10
Employee B Using a Combination of Overtime and Sick Leave

Employee B's Regular Work Schedule

DAY OFF

REG. SHIFT

REG. SHIFT

REG. SHIFT

DAY OFF

REG. SHIFT

REG. SHIFT

Employee B's Amended Work Schedule

OT SHIFT

SICK LEAVE

SICK LEAVE

SICK LEAVE

OT SHIFT

SICK LEAVE

SICK LEAVE

Not e: Days shaded gr ay i ndi cat e days Empl oyee B i s not pr esent at wor k.

I n t he scenar i o i l l ust r at ed i n Fi gur e 3. 10, Empl oyee B' s
r egul ar wor k schedul e i s a 40- hour wor k week wi t h t wo days of f .
I f Empl oyee B t akes si ck l eave benef i t s dur i ng t he f i ve
r egul ar l y schedul ed shi f t s and wor ks over t i me shi f t s dur i ng t he
t wo r egul ar l y schedul ed days of f , Empl oyee B wi l l per f or ma 16-
hour wor k week and be compensat ed f or t he f i ve days of si ck
l eave and t wo days of over t i me. Thus, Empl oyee B wi l l r ecei ve
gr eat er compensat i on f or wor ki ng si gni f i cant l y f ewer hour s t han
Empl oyee B' s r egul ar wor k schedul e.

The I nvest i gat i ve Commi t t ee not es t hat an empl oyee i s
r equi r ed t o submi t a not e f r omt he empl oyee' s doct or f or f i ve or
mor e consecut i ve days of pai d si ck l eave, but i s al l owed t o t ake
f i ve or mor e nonconsecut i ve days of pai d si ck l eave or f our or
f ewer consecut i ve days of pai d si ck l eave as l ong as t he
empl oyee has accumul at ed enough pai d si ck l eave hour s.
182
I n t he
scenar i o i l l ust r at ed i n Fi gur e 3. 10, a doct or ' s not e i s not
r equi r ed because Empl oyee B' s f i ve t ot al days of pai d si ck l eave
ar e composed of t hr ee consecut i ve days and t wo consecut i ve days
wi t h an over t i me shi f t bet ween t he t wo per i ods of si ck l eave.
The I nvest i gat i ve Commi t t ee f ur t her not es t hat Empl oyee B' s f i ve
days of pai d si ck l eave cr eat e f i ve addi t i onal oppor t uni t i es f or
ot her empl oyees t o per f or man over t i me shi f t i f t hese empl oyees
ar e el i gi bl e and avai l abl e.

182

Figure 3.11
Employee C Cooperating with Employee D to Use Employee D's Sick
Leave for an Overtime Shift

Regular Work Schedule Amended Work Schedule
Shift Employee C Employee D Shift Employee C Employee D
7A
OFF

OFF
7A
OFF

OFF | |
3P 3P
3P
REG. SHIFT

OFF
3P
REG. SHIFT

OFF | |
11P 11P
11P
OFF

REG. SHIFT
11P
OT SHIFT

SICK LEAVE | |
7A 7A

Not e: Shi f t s shaded gr ay i ndi cat e shi f t s f or whi ch Empl oyee C or D ar e not
schedul ed.

I n t he scenar i o i l l ust r at ed i n Fi gur e 3. 11, Empl oyee C i s
schedul ed t o wor k t he eveni ng shi f t f r om3: 00 t o 11: 00 p. m. and
Empl oyee D i s schedul ed t o wor k t he ni ght shi f t f r om11: 00 p. m.
t o 7: 00 a. m. Empl oyees C and D coul d cooper at e so t hat Empl oyee
D cal l s t he Nur si ng Of f i ce t o t ake si ck l eave f or t he ni ght
shi f t . Shor t l y t her eaf t er , Empl oyee C coul d not i f y t he Nur si ng
Of f i ce of Empl oyee C' s avai l abi l i t y t o wor k t he ni ght shi f t f or
whi ch Empl oyee D has t aken si ck l eave, af t er Empl oyee C' s
r egul ar schedul ed eveni ng shi f t . As a r esul t , Empl oyee C gai ns
an over t i me shi f t whi l e Empl oyee D i s compensat ed f or a shi f t
due t o pai d si ck l eave benef i t s. The I nvest i gat i ve Commi t t ee
not es t hat t hi s scenar i o i s onl y possi bl e i f Empl oyee C i s i n
t he f r ont of t he r ot at i on. However , Ms. Ono t est i f i ed t hat she
not i ces t hi s t ype of concer t ed ef f or t about t wo t o t hr ee t i mes
per week and t hat t her e ar e some empl oyees who coi nci dent l y
appear t o gai n over t i me shi f t s si mi l ar t o t hi s scenar i o.
183

Al t hough t he I nvest i gat i ve Commi t t ee r ecogni zes t hat
over t i me and pai d si ck l eave benef i t s ar e gr ant ed t o t he
empl oyees and negot i at ed f or i n t hei r col l ect i ve bar gai ni ng
agr eement s, i t bel i eves t hat bet t er mechani sms need t o be
i mpl ement ed t o cont r ol or r educe t he r i sk of some empl oyees
t aki ng advant age of t hei r over t i me and si ck l eave benef i t s f or
t hei r own f i nanci al gai n. Over t i me, such abuse has a f i nanci al
i mpact t o t he Hospi t al ' s per sonnel budget and adds t o t he
Hospi t al ' s chal l enges i n acqui r i ng suf f i ci ent st af f t o car e f or
and meet t he cl i ni cal needs of pat i ent s.

183

d. Collective Bargaining Agreements Impact Overtime
Benefits

The I nvest i gat i ve Commi t t ee f i nds t hat col l ect i ve
bar gai ni ng i mpact s t he Hospi t al ' s abi l i t y t o l i mi t or cont r ol
over t i me. I n 1996, t he Hospi t al was or der ed by t he f eder al
cour t t o " adopt and i mpl ement a pol i cy t hat no [ Hospi t al ]
empl oyee wor ks vol unt ar y over t i me on consecut i ve days and t hat
l i mi t s t he number of vol unt ar y over t i me shi f t s f or each empl oyee
t o a maxi mumof t hr ee shi f t s per week. "
184
However , t hi s or der
l i mi t i ng over t i me was evi dent l y not i mpl ement ed due t o st at e
col l ect i ve bar gai ni ng l aws.
185
concer ned wi t h and i nt er est ed i n t he r econci l i at i on of t he
f eder al cour t or der and col l ect i ve bar gai ni ng agr eement s.

Accor di ng t o t he Depar t ment of t he At t or ney Gener al ,
changes i n over t i me oppor t uni t i es af f or ded t o publ i c sect or
empl oyees i n Hawai i ar e gener al l y subj ect t o mut ual consent
absent a j udi ci al decr ee speci f i cal l y suspendi ng col l ect i ve
bar gai ni ng.
186
The or der di r ect i ng t he Hospi t al t o i mpl ement an
over t i me pol i cy di d not cont ai n a cl ause speci f i cal l y suspendi ng
any aspect of t he r el at i ve col l ect i ve bar gai ni ng agr eement s.
187

Ther ef or e, t he Depar t ment concl uded t hat t he af f ect ed publ i c
empl oyee uni ons woul d t ake t he posi t i on t hat t he pr oposed
over t i me pol i cy modi f i cat i ons under t he or der const i t ut ed
mat er i al changes t o hour s, wages, and condi t i on of wor k set
f or t h i n t hei r col l ect i ve bar gai ni ng agr eement s and t hat mut ual
consent was necessar y t o i mpl ement t hese over t i me pol i ci es.
188

The Hospi t al was not successf ul i n obt ai ni ng consent f r omt he
Uni t ed Publ i c Wor ker s uni on and accor di ngl y, t he over t i me
pol i ci es pr escr i bed under t he or der wer e not i mpl ement ed.
189

Whi l e t he I nvest i gat i ve Commi t t ee not es t he concl usi ons
submi t t ed by t he Depar t ment of t he At t or ney Gener al , i t bel i eves
t hat t hi s concl usi on onl y appl i es t o t he 1996 or der and shoul d
not appl y t o or pr event t he i mpl ement at i on of any subsequent
184
Uni t ed St at es v. St at e of Hawai i , et al . , St i pul at i on and Or der , Ci vi l No.
91- 00137 DAE ( 1996) ( LR_07_0154- 0167) .
185
186
Let t er t o Li nda Rosen, Di r ect or of Heal t h f r omJ ames Hal vor son, Deput y
At t or ney Gener al of t he Depar t ment of t he At t or ney Gener al Empl oyment
Di vi si on, dat ed Apr i l 8, 2014 ( LR_040914_0001- 0003) .
187
188
189

ef f or t s by t he Hospi t al t o cont r ol over t i me. I nst ead, t he
Hospi t al shoul d consul t and cooper at e wi t h t he r espect i ve uni ons
t o devel op and i mpl ement a sol ut i on t hat wi l l decr ease per sonnel
cost s and f ol l ow col l ect i ve bar gai ni ng l aws and agr eement s.

The I nvest i gat i ve Commi t t ee f ur t her not es t hat i n August
2014, t he Ci t y and Count y of Honol ul u and t he Uni t ed Publ i c
Wor ker s uni on r eached an agr eement t hat al l ows par amedi cs and
emer gency medi cal t echni ci ans t o wor k l onger shi f t s, but shor t er
weeks.
190
Thi s agr eement i s expect ed t o r educe t he amount of
over t i me of emer gency medi cal ser vi ce wor ker s, save t he Ci t y and
Count y of Honol ul u appr oxi mat el y $1. 5 mi l l i on annual l y i n
over t i me, and mai nt ai n saf e wor ker per f or mance st andar ds.
191

Accor di ngl y, t he Hospi t al shoul d make si mi l ar ef f or t s t o r each
an agr eement wi t h t he uni ons.

Fur t her mor e, t he I nvest i gat i ve Commi t t ee f i nds t hat
col l ect i ve bar gai ni ng af f ect s t he over t i me assi gnment s. I n
addi t i on t o t he r ot at i on, over t i me assi gnment s ar e af f ect ed by
whet her a nur se st af f member i s a ci vi l ser vant or under
cont r act wi t h a pr i vat e sect or t empor ar y empl oyee ser vi ce
agency.
192
Ci vi l ser vant s ar e f i r st of f er ed over t i me
oppor t uni t i es.
193
When t he l i st of el i gi bl e and avai l abl e ci vi l
ser vant s i s exhaust ed, t he Hospi t al t hen of f er s t hese shi f t s t o
pr i vat e sect or t empor ar y empl oyee agency wor ker s.
194

Mr . El l i ot t expl ai ned t hat t hi s pr act i ce i s based on t he
Konno deci si on.
195

196
I n Konno, t he Hawai i Supr eme Cour t not ed
t hat " t he ci vi l ser vi ce, as def i ned by [ 76- 77, HRS] ,
encompasses t hose ser vi ces t hat have been cust omar i l y and
hi st or i cal l y pr ovi ded by ci vi l ser vant s"
197
and absent expr ess
l egi sl at i ve aut hor i t y t o obt ai n ser vi ces f r omot her sour ces,
ci vi l ser vant s must pr ovi de t hese ser vi ces. Si nce t he Hospi t al
pr ovi des ser vi ces t hat ar e cust omar i l y and hi st or i cal l y pr ovi ded
by ci vi l ser vant s, over t i me oppor t uni t i es must f i r st be of f er ed
t o ci vi l ser vant s bef or e pr i vat e sect or agency empl oyees.

However , t he I nvest i gat i ve Commi t t ee f i nds t hat t he syst em
of assi gni ng over t i me shi f t s t o ci vi l ser vant s bef or e agency
190
Gor don Y. K. Pang, Agreement reached on 12-hour shifts for paramedics, EMTs,
St ar - Adver t i ser ( August 11, 2014) .
191
Gor don Y. K. Pang, Agreement reached on 12-hour shifts for paramedics, EMTs,
St ar - Adver t i ser ( August 11, 2014) .
192
Test i mony of Debr a Ono, May 14, 2014; Test i mony of Leona Guest , J une 18,
2014; and Test i mony of Wi l l i amEl l i ot t , J une 18, 2014.
193
Test i mony of Leona Guest and Wi l l i amEl l i ot t , J une 18, 2014.
194
Test i mony of Leona Guest and Wi l l i amEl l i ot t , J une 18, 2014.
195
196
Konno v. Count y of Hawai i , 85 Haw. 61, 937 P. 2d 397 ( 1997) .
197
Konno v. Count y of Hawai i , 85 Haw. 61, 72, 937 P. 2d 397, 409 ( 1997) .

wor ker s can r esul t i n hi gher per sonnel cost s f or t he Hospi t al .
Dur i ng t he I nvest i gat i ve Commi t t ee' s si t e vi si t t o t he Hospi t al
i n J une 2014, i t obser ved a Regi st er ed Nur se ( RN) ser vi ng as a
Psychi at r i c Techni ci an ( Psych Tech) f or an over t i me shi f t .
Assumi ng t hat t hi s RN' s base pay i s hi gher t han a Psych Tech' s
base pay t he RN i s f i l l i ng i n f or , t he over t i me cost s f or t he RN
ar e gr eat er t han havi ng an agency wor ker ser ve as a Psych Tech
f or t hat over t i me shi f t . The I nvest i gat i ve Commi t t ee i s
concer ned t hat t hi s pr i or i t y syst emf or assi gni ng over t i me
cr eat es a gr eat er oppor t uni t y f or ci vi l ser vant s wi t h hi gher
sal ar i es t o t ake advant age of t he over t i me syst emf or f i nanci al
gai n. Thi s i s nei t her cost ef f ect i ve nor f ai r , especi al l y when
ser vi ce cont r act s wi t h pr i vat e pr ovi der s can enabl e t he Hospi t al
t o obt ai n necessar y addi t i onal st af f and r educe per sonnel cost s.

The I nvest i gat i ve Commi t t ee not es l egi sl at i on pr oposed by
t he Depar t ment of t he At t or ney Gener al
198
t o pr ovi de st at e
i nst i t ut i ons wi t h 24 hour s a day, seven days a week st af f i ng
r esponsi bi l i t i es gr eat er f l exi bi l i t y t o ef f ect i vel y deal wi t h
st af f i ng shor t ages, excessi ve use of over t i me by ci vi l ser vi ce
st af f , and consequent heal t h and saf et y i ssues ar i si ng t her ef r om
by speci f i cal l y al l owi ng t hese st at e i nst i t ut i ons t o use pr i vat e
st af f i ng cont r act or s t o al l evi at e day- t o- day st af f i ng shor t ages
wi t hout f i r st of f er i ng over t i me oppor t uni t i es t o ci vi l ser vi ce
st af f . Thi s t ype of exempt i on woul d pr ovi de a mor e cost -
ef f ect i ve al t er nat i ve t o cont r ol l i ng over t i me whi l e enabl i ng t he
Hospi t al t o meet i t s st af f i ng r equi r ement s.

3. The Handling of Employee Complaints and Disciplinary
Actions Lacks Transparency and Due Process

Fr omJ anuar y 2009 t o Mar ch 2014, t her e have been over 180
compl ai nt s f i l ed r egar di ng wor kpl ace vi ol ence, har assment , or
di scr i mi nat i on at t he Hospi t al .
199
The compl ai nt s i ncl ude but
ar e not l i mi t ed t o i nappr opr i at e wor kpl ace behavi or or t he
compl ai nant f eel i ng humi l i at ed, t ar get ed, or t hr eat ened.
200

These compl ai nt s appear t o be gener al l y r esol ved by a di scussi on
wi t h t he empl oyee or a wr i t t en r epr i mand, but t her e ar e out comes
i ndi cat i ng t hat t he empl oyee i s no l onger wi t h t he Hospi t al or
was t r ansf er r ed t o anot her uni t .
201
The I nvest i gat i ve Commi t t ee
198
Pr oposed l egi sl at i on submi t t ed by t he Depar t ment of t he At t or ney t o t he
I nvest i gat i ve Commi t t ee i n r esponse t o i nqui r i es r egar di ng how t he Konno
deci si on af f ect s t he assi gnment of over t i me oppor t uni t i es and ways t o addr ess
t he i ssue. See, At t achment A.
199
Depar t ment of Heal t h, HSH Empl oyee I nci dent Repor t Wor kpl ace
Vi ol ence/ Har assment / Di scr i mi nat i on ( LR_20_0014- 0031 Conf i dent i al ) .
200
201

i s concer ned over t he number of wor kpl ace vi ol ence, har assment ,
or di scr i mi nat i on compl ai nt s and not es t he concer ns r ai sed by
sever al Hospi t al empl oyees who ar e not awar e of t he st at us of
t hei r compl ai nt s or t he r easons f or di sci pl i nar y act i ons t aken
agai nst t hem. The I nvest i gat i ve Commi t t ee f i nds t hat t he
Hospi t al ' s handl i ng of t hese compl ai nt s l acks t r anspar ency and
due pr ocess.

a. Lack of Policies and Procedures to Assure that an
Employee's Complaint is Handled in a Transparent
and Fair Manner

Whi l e t he Hospi t al has pol i ci es and pr ocedur es f or f i l i ng
and i nvest i gat i ng empl oyee compl ai nt s, t he I nvest i gat i ve
Commi t t ee f i nds a l ack of pr ocedur es t o ensur e t hat t he empl oyee
compl ai nant i s i nf or med of t he st at us and out come of t he
compl ai nt and t o pr escr i be pr oper conduct of t he empl oyee
compl ai nant and t he empl oyee agai nst whomt he compl ai nt i s f i l ed
dur i ng t he i nvest i gat i on. Such pr ocedur es wi l l ensur e t hat
empl oyee compl ai nt s and any r esul t i ng di sci pl i nar y act i ons ar e
handl ed i n a f ai r and t r anspar ent manner .

The I nvest i gat i ve Commi t t ee f i nds t hat t he Hospi t al l acks
pol i ci es and pr ocedur es t o pr escr i be appr opr i at e conduct dur i ng
an ongoi ng i nvest i gat i on. For exampl e, on November 4, 2013,
Uni t H Psychi at r i c Techni ci an, Ryan Oyama, f i l ed an empl oyee
i nci dent r epor t agai nst hi s Uni t H Nur se Manager Candace
Sul l i van.
202
Mr . Oyama al l eged t hat Ms. Sul l i van t hr eat ened t hat
she coul d cr eat e a sexual har assment case agai nst Mr . Oyama and
have hi mf i r ed
203
af t er he di scl osed t o her t hat he di d a
t el evi si on news i nt er vi ew about t he i nj ur i es he sust ai ned whi l e
wor ki ng at t he Hospi t al .
204
As a r esul t , Mr . Oyama f ear ed t hat
he woul d l ose hi s j ob and st at ed i n t he empl oyee i nci dent
r epor t , " bei ng t hr eat ened by my super vi sor was an uncomf or t abl e
and f ear f ul si t uat i on. "
205
Subsequent l y, Mr . Oyama and hi s wi f e
r ecei ved voi cemai l messages on t hei r per sonal cel l ul ar phones
f r omMs. Sul l i van aski ng f or Mr . Oyama t o cal l her and cl ear up
t he si t uat i on.
206
Mr . Oyama di d not cal l Ms. Sul l i van.
207
Mr .
Oyama t est i f i ed t hat t o hi s knowl edge, hi s compl ai nt i s st i l l
ongoi ng and he has not r ecei ved any updat es f r omt he Hospi t al
202
Empl oyee I nci dent Repor t submi t t ed by Ryan Oyama t o t he I nvest i gat i ve
Commi t t ee on Sept ember 16, 2014 pur suant t o a subpoena duces t ecum.
203
204
Test i mony of Ryan Oyama, Sept ember 16, 2014.
205
206
207

r egar di ng i t s st at us.
208
di scover ed t hat Ms. Sul l i van r ecei ved a wr i t t en r epr i mand as a
r esul t of Mr . Oyama' s compl ai nt .
209

The I nvest i gat i ve Commi t t ee has deep concer ns r egar di ng Ms.
Sul l i van' s numer ous at t empt s t o cont act Mr . Oyama whi l e t he
compl ai nt i s st i l l open. Ms. Sul l i van t est i f i ed t hat she
r epeat edl y t r i ed t o cont act Mr . Oyama because she di d not
under st and why he woul d f i l e a compl ai nt agai nst her due t o
t hei r f r i endshi p.
210
Fi nal l y, Ms. Sul l i van was advi sed by Ms.
Guest t o st op cont act i ng Mr . Oyama and t o al l ow t he pr ocess t o
t ake car e of t he si t uat i on.
211
Ms. Guest t est i f i ed t hat she i s
not awar e of any pol i ci es or pr ocedur es t hat pr ohi bi t a per son
agai nst whoma compl ai nt was f i l ed f r ommaki ng cont act wi t h t he
compl ai nant whi l e t he compl ai nt i s st i l l open.
212
The
I nvest i gat i ve Commi t t ee f i nds t hat Ms. Sul l i van' s at t empt s t o
cont act Mr . Oyama may be consi der ed a f or mof i nt i mi dat i on and
has concer ns t hat t hi s conduct wi l l di scour age empl oyees f r om
f i l i ng a compl ai nt . Speci f i c Hospi t al pr ocedur es est abl i shi ng
per mi ssi bl e and pr ohi bi t ed conduct whi l e a compl ai nt i s open
assi st s i n ensur i ng t hat t he i nvest i gat i on and di sposi t i on of a
compl ai nt ar e compl et ed i n a f ai r manner .

Fur t her mor e, t he I nvest i gat i ve Commi t t ee f i nds t hat t he
Hospi t al l acks pol i ci es and pr ocedur es t hat ensur e t hat t he
empl oyee compl ai nant i s i nf or med of t he st at us and out come of
t he compl ai nt . For exampl e, i n December 2013, Uni t H st af f
member , J ayl i ng Fer nandez, f i l ed an empl oyee i nci dent r epor t
agai nst Ms. Sul l i van.
213
Ms. Fer nandez al l eged t hat Ms. Sul l i van
accused her of wr i t i ng an anonymous l et t er t o Hospi t al
admi ni st r at or s r egar di ng Ms. Sul l i van' s behavi or and r emar ks
dur i ng a pr evi ous st af f meet i ng.
214
Subsequent l y, Ms. Fer nandez
was t r ansf er r ed t o anot her uni t whi l e t he i nvest i gat i on was
ongoi ng.
215
I n J une 2014, Ms. Fer nandez r ecei ved a copy of t he
empl oyee i nci dent r epor t she submi t t ed i n December 2013, wi t h
handwr i t t en comment s f r omMs. Guest t o cl ose t he
208
209
Depar t ment of Heal t h, Document s r el at i ng t o t he cl osi ng of Empl oyee
I nci dent Repor t submi t t ed by J ayl i ng Fer nandez ( LR_092914_3_1- 3 -
210
Test i mony of Candace Sul l i van, Sept ember 16, 2014.
211
Test i mony of Candace Sul l i van and Leona Guest , Sept ember 16, 2014.
212
Test i mony of Leona Guest , Sept ember 16, 2014.
213
Depar t ment of Heal t h, Document s r el at i ng t o Empl oyee I nci dent Repor t f i l ed
by J ayl i ng Fer nandez ( LR_092914_1_1- 4 - Conf i dent i al ) .
214
215
Depar t ment of Heal t h, Document s r el at i ng t o Gui del i nes of I nvest i gat i on
i nt o Empl oyee I nci dent Repor t f i l ed by J ayl i ng Fer nandez ( LR_092914_9_1- 5 -

i nvest i gat i on.
216
To dat e, Ms. Fer nandez has not seen a copy of
t he At t or ney Gener al ' s i nvest i gat i on r epor t and does not know
t he out come, i f any, of her compl ai nt . However , t he
I nvest i gat i ve Commi t t ee di scover ed t hat Ms. Sul l i van r ecei ved a
wr i t t en r epr i mand as a r esul t of Ms. Fer nandez' s compl ai nt .
217

Whi l e t he I nvest i gat i ve Commi t t ee r ecogni zes t he i mpor t ance
of ensur i ng t hat an empl oyee agai nst whoma compl ai nt i s f i l ed
i s pr ovi ded due pr ocess, i t f i nds t hat i t i s equal l y i mpor t ant
t o keep t he empl oyee compl ai nant i nf or med of t he st at us and
out come of t he i nvest i gat i on wi t hout vi ol at i ng any pr i vacy l aws.
I n Ms. Fer nandez' s case, she was i nf or med onl y t hat her
compl ai nt was cl osed, whi l e Mr . Oyama st i l l assumes t hat hi s
case i s st i l l open even t hough Ms. Sul l i van has r ecei ved a
wr i t t en r epr i mand and t he case i s cl osed.
218
Pol i ci es and
pr ocedur es wi l l ensur e t hat t he handl i ng and i nvest i gat i on of
empl oyee compl ai nt s ar e handl ed i n a t r anspar ent manner . The
I nvest i gat i ve Commi t t ee i s concer ned t hat f ai l ur e t o i nf or m
empl oyees of t he st at us and out come of t hei r compl ai nt s wi l l
di scour age ot her empl oyees f r omf i l i ng compl ai nt s.

b. Weak Policies and Procedures to Ensure Due
Process for an Employee Against Whom a Complaint
is Filed

Whi l e t he Hospi t al has pol i ci es and pr ocedur es f or f i l i ng
and i nvest i gat i ng empl oyee compl ai nt s, t he I nvest i gat i ve
Commi t t ee f i nds t hat t hese pr ocedur es need t o be st r engt hened t o
ensur e t hat t he empl oyee agai nst whoma compl ai nt i s f i l ed i s
pr ovi ded due pr ocess. For exampl e, f our pat i ent event r epor t s
wer e f i l ed agai nst Uni t H Psychi at r i c Techni ci an, Kal f or d Keanu,
J r . , f or f our al l egat i ons dur i ng t wo i nci dent s i nvol vi ng t he
same pat i ent t hat occur r ed on Oct ober 9, 2012.
219
The pat i ent
event r epor t s al l ege t hat Mr . Keanu per f or med Cont r ol l ed Pat i ent
Management Resol ut i on ( CPMR) wal l cont ai nment pr ocedur es on a
pat i ent t hat r esul t ed i n pat i ent i nj ur i es and he l ef t hi s 1: 1
assi gnment unat t ended t o per f or mCPMR wal l cont ai nment
216
217
conf i dent i al ) .
218
conf i dent i al ) .
219
I nvest i gat i on r epor t and ot her r el at ed document s r egar di ng Kal f or d Keanu,
J r . , submi t t ed by Kal f or d Keanu, J r . t o t he I nvest i gat i ve Commi t t ee on May
14, 2014.

pr ocedur es.
220
Mr . Keanu was t r ansf er r ed out of Uni t H and
assi gned t o wor k i n t he Nur si ng Of f i ce whi l e t he Depar t ment of
t he At t or ney Gener al conduct ed i t s i nvest i gat i on.
221
On Apr i l
23, 2013, Mr . Keanu r ecei ved a l et t er dur i ng hi s meet i ng wi t h
Ms. Sul l i van and Ms. Guest . The l et t er ser ved as a wr i t t en
r epr i mand f or pat i ent abuse and negl ect and unwar r ant ed
aggr essi ve behavi or , r equi r ed Mr . Keanu t o at t end an anger
management wor kshop, and of f er ed hi ma j ob t r ansf er f r omUni t H
t o anot her uni t .
222
Mr . Keanu t est i f i ed t hat he r ef used t o si gn
t he l et t er , but at t ended t he r equi r ed anger management wor kshop
and r equest ed t o be t r ansf er r ed t o Uni t U.
223
Fur t her mor e, Mr .
Keanu t est i f i ed t hat Ms. Sul l i van and Ms. Guest deni ed hi s
r equest f or a uni on r epr esent at i ve t o be pr esent dur i ng t hei r
meet i ng.
224

Subsequent l y, Mr . Keanu was abl e t o r ead a copy of t he
At t or ney Gener al ' s i nvest i gat i on r epor t ,
225
whi ch he was
pr evi ousl y deni ed access t o vi ew. UPWf i l ed a gr i evance
226
on
behal f of Mr . Keanu t hat t he Hospi t al f ai l ed t o, among ot her
i t ems, est abl i sh j ust and pr oper cause bef or e i ssui ng a wr i t t en
r epr i mand and r evi ew and consi der al l evi dence, dat a, and
f act or s suppor t i ng Mr . Keanu bef or e maki ng a deci si on.

The I nvest i gat i ve Commi t t ee i s deepl y concer ned t hat Mr .
Keanu was di sci pl i ned wi t hout due pr ocess. The Hospi t al ' s
pol i ci es and pr ocedur es gener al i ze t he r i ght s and dut i es t hat
ar e af f or ded t o an accused empl oyee, i ncl udi ng t he r i ght t o be
r epr esent ed by t he empl oyee' s uni on and bei ng pr ovi ded t he
speci f i c r easons f or t he di sci pl i nar y act i ons. I n Mr . Keanu' s
case, he was pr ovi ded a wr i t t en r epr i mand wi t hout bei ng al l owed
r epr esent at i on by hi s uni on upon hi s r equest . The wr i t t en
r epr i mand expl ai ned t hat he was bei ng r epr i manded f or l eavi ng
hi s 1: 1 assi gnment unat t ended t o assi st a cowor ker wi t h a
pat i ent and usi ng excessi ve f or ce t hat r esul t ed i n a pat i ent
220
14, 2014.
221
Test i mony of Kal f or d Keanu, J r . , May 14, 2014.
222
14, 2014.
223
224
225
14, 2014.
226
14, 2014.

i nj ur y.
227
However , t he At t or ney Gener al ' s i nvest i gat i on di d not
subst ant i at e t hat Mr . Keanu used excessi ve f or ce or l eave hi s
1: 1 assi gnment unat t ended.
228
The I nvest i gat i ve Commi t t ee does
not under st and how Mr . Keanu was r epr i manded f or t hose act i ons
when t he At t or ney Gener al f ound no wr ongdoi ng.

The I nvest i gat i ve Commi t t ee i s al so concer ned t hat Mr .
Keanu was not al l owed t o see a copy of t he At t or ney Gener al ' s
i nvest i gat i on r epor t . Accor di ng t o t he Deput y At t or ney Gener al ,
J ames Hal vor son, who i s t he Super vi sor of t he Depar t ment of t he
At t or ney Gener al ' s Empl oyment Law Di vi si on, t he Depar t ment
gener al l y advi ses ot her st at e depar t ment s and agenci es t o keep
At t or ney Gener al i nvest i gat i on r epor t s conf i dent i al i f t he st at e
depar t ment or agency i s not t aki ng any adver se act i on.
229
The
I nvest i gat i ve Commi t t ee f i nds t hat because Mr . Keanu r ecei ved a
wr i t t en r epr i mand, he shoul d have been abl e t o r ecei ve a copy of
t he i nvest i gat i on r epor t i n or der t o be i nf or med of t he
al l egat i ons made agai nst hi mand t he evi dence pr ovi ng t hese
al l egat i ons.

The I nvest i gat i ve Commi t t ee not es t hat Mr . Hal vor son added
t hat t her e may be a si t uat i on wher e an i nvest i gat i on concl udes
no wr ongdoi ng, but t hat a st at e depar t ment t akes an adver se
posi t i on because based on t he i nvest i gat i on, t he st at e
depar t ment f i nds a l esser degr ee of wr ongdoi ng.
230
I n ot her
wor ds, t he i nvest i gat i on subst ant i at ed a l esser degr ee of
wr ongdoi ng. However , t he I nvest i gat i ve Commi t t ee f i nds t hat i f
t he Hospi t al f ound t hat Mr . Keanu commi t t ed a l esser degr ee of
wr ongdoi ng, t hen he shoul d have been i nf or med of t hi s. The
wr i t t en r epr i mand does not i ndi cat e t hi s and i nst ead i nf or ms Mr .
Keanu of wr ongdoi ng t hat t he At t or ney Gener al ' s i nvest i gat i on
r epor t coul d not subst ant i at e.

The I nvest i gat i ve Commi t t ee has ser i ous concer ns r egar di ng
t he f ai r ness and t r anspar ency wi t h whi ch t he Hospi t al handl ed
Mr . Keanu' s case and Mr . Hal vor son' s r easons f or keepi ng
i nvest i gat i ons conf i dent i al f r omt he empl oyee who was
i nvest i gat ed. Empl oyee compl ai nt s and any associ at ed
i nvest i gat i ons coul d damage an empl oyee' s r eput at i on and car eer .
Whi l e t he I nvest i gat i ve Commi t t ee r ecogni zes t he need t o keep
per sonnel mat t er s conf i dent i al and not es t he pr i vacy l aws under
chapt er 92F, HRS, i t f i nds t hat Hospi t al pol i ci es and pr ocedur es
227
14, 2014.
228
J r , submi t t ed by Kal f or d Keanu, J r . t o t he I nvest i gat i ve Commi t t ee on May 14,
2014.
229
Test i mony of J ames Hal vor son, on behal f of Mar k Fr i dovi ch, J ul y 16, 2014.
230
Test i mony of J ames Hal vor son, on behal f of Mar k Fr i dovi ch, J ul y 16, 2014.

need t o be st r engt hened t o ensur e t hat empl oyees who ar e al l eged
t o have commi t t ed a wr ongdoi ng ar e pr ovi ded due pr ocess, whi l e
pr ot ect i ng empl oyee pr i vacy r i ght s and pr event i ng r et al i at i on.

c. Employees Fear Retaliation by Hospital
Administrators and Supervisors

I t appear s t o t he I nvest i gat i ve Commi t t ee t hat t her e i s a
hi st or y of r et al i at or y act i ons and act s of i nt i mi dat i on
exer ci sed by Hospi t al admi ni st r at or s and super vi sor s. For
exampl e, whi l e t hei r i nvest i gat i ons wer e pendi ng, Mr . Keanu and
Ms. Fer nandez wer e t r ansf er r ed out of Uni t H and have not been
t r ansf er r ed back t o Uni t H even af t er t hei r i nvest i gat i ons have
been cl osed.
231
The I nvest i gat i ve Commi t t ee not es t hat t hese
t r ansf er s coul d be consi der ed a f or mof r et al i at i on by t he
Hospi t al admi ni st r at i on especi al l y when Ms. Sul l i van was not
t r ansf er r ed out of Uni t H. Fur t her mor e, i t appear s t hat t he
compl ai nt s f i l ed by Mr . Oyama and Ms. Fer nandez agai nst Ms.
Sul l i van wer e based on al l egat i ons of har assment and
i nt i mi dat i on. Mr . Oyama al l eges t hat Ms. Sul l i van t hr eat ened
Mr . Oyama' s j ob, whi l e Ms. Fer nandez al l eges t hat Ms. Sul l i van
f al sel y accused her of wr i t i ng an anonymous l et t er t o Hospi t al
admi ni st r at or s. The I nvest i gat i ve Commi t t ee consi der s t hese
al l egat i ons, i f t r ue, as f or ms of i nt i mi dat i on by a super vi sor
and st r ongl y bel i eves t hat such act s as wel l as f or ms of
r et al i at i on ar e unaccept abl e, i nexcusabl e, and det r i ment al t o
empl oyee mor al e and wor k per f or mance.

The I nvest i gat i ve Commi t t ee i s deepl y concer ned t hat f ear s
of r et al i at i on di scour age and pr event empl oyees f r omcomi ng
f or war d wi t h wor kpl ace saf et y or human r esour ces i ssues.
Fai l ur e t o communi cat e pr obl ems up t he chai n of command pr event s
t he Hospi t al f r omdevel opi ng and i mpl ement i ng sol ut i ons t o
pr ovi de a bet t er wor k envi r onment f or i t s empl oyees and cr eat es
a gr eat er di vi de bet ween Hospi t al admi ni st r at or s and st af f ,
whi ch can negat i vel y i mpact pat i ent car e.

Addi t i onal l y, t he I nvest i gat i ve Commi t t ee has ser i ous
concer ns r egar di ng t he management ski l l s of Ms. Sul l i van. The
I nvest i gat i ve Commi t t ee not es t hat al l t hr ee i nci dent s ment i oned
above di r ect l y or i ndi r ect l y i nvol ved Ms. Sul l i van. Uni t H
ser ves as an acut e uni t as wel l as t he admi ssi ons uni t f or t he
Hospi t al . Thus, i t i s i mper at i ve f or Ms. Sul l i van, as t he Nur se
Manager f or Uni t H, t o ensur e t hat t he st af f assi gned t o Uni t H
ar e pr ovi ded a saf e wor k envi r onment i n or der t o pr oper l y car e
f or t he uni t ' s wi de spect r umof pat i ent s. However , when Uni t H
231
Depar t ment of Heal t h, Document s r el at i ng t o Gui del i nes of I nvest i gat i on
i nt o Empl oyee I nci dent Repor t f i l ed by J ayl i ng Fer nandez ( LR_092914_9_1- 4- 5 -
conf i dent i al ) and Test i mony of Kal f or d Keanu, J r . , May 14, 2014.

empl oyees f ear r et al i at i on f r omor ar e i nt i mi dat ed by Ms.
Sul l i van, i t er odes empl oyee t r ust , whi ch, i n t ur n, i mpact s
empl oyee mor al e and wor k per f or mance.

The I nvest i gat i ve Commi t t ee f ur t her not es t hat Ms. Sul l i van
r ecei ved a l et t er dat ed J ul y 1, 2014, t hat ser ved as wr i t t en
r epr i mand f or unpr of essi onal conduct r el at i ng t o her
i nt er act i ons wi t h st af f , whi ch wer e i nvest i gat ed by t he
Depar t ment of t he At t or ney Gener al .
232
She was speci f i cal l y
r epr i manded f or her separ at e i nt er act i ons wi t h Mr . Oyama and Ms.
Fer nandez.
233
As a r esul t , she was r equi r ed t o at t end t he
" Addr essi ng Emot i ons at Wor k" t r ai ni ng on Sept ember 19, 2014.
234

The I nvest i gat i ve Commi t t ee not es t hat Ms. Sul l i van r ef used t o
si gn t he l et t er
235
and HGEA has f i l ed a gr i evance on her
behal f .
236
Wi t h r egar d t o t he r equi r ed cl ass, t he I nvest i gat i ve
Commi t t ee di scover ed f r omMr . May t hat due t o a
mi scommuni cat i on, Ms. Sul l i van was unabl e t o r egi st er f or t he
t r ai ni ng and wi l l be r equi r ed t o at t end t he next schedul ed
t r ai ni ng i n Febr uar y 2015. Accor di ngl y, t he I nvest i gat i ve
Commi t t ee has concer ns r egar di ng whet her t he wr i t t en r epr i mand
adequat el y or ef f ect i vel y r emedi es t he compl ai nt s f i l ed agai nst
Ms. Sul l i van, especi al l y when Mr . Oyama and Ms. Fer nandez ar e
unawar e t hat Ms. Sul l i van r ecei ved a wr i t t en r epr i mand, f i l ed a
gr i evance t hr ough her uni on, and t hat she wi l l not be abl e t o
at t end t he " Addr essi ng Emot i ons at Wor k" t r ai ni ng unt i l next
year . I n addi t i on, t he I nvest i gat i ve Commi t t ee i s concer ned
t hat t hese ci r cumst ances may i mpact or di scour age ot her
empl oyees f r omf i l i ng compl ai nt s when t hey exper i ence
r et al i at or y act i ons or act s of i nt i mi dat i on exer ci sed by
Hospi t al admi ni st r at or s and super vi sor s.

Last l y, t he I nvest i gat i ve Commi t t ee not es t hat dur i ng i t s
hear i ng on Sept ember 16, 2014, Ms. Sul l i van made cont r adi ct or y
st at ement s whi l e under oat h. Speci f i cal l y, Ms. Sul l i van
t est i f i ed t hat Mr . Oyama was t he onl y empl oyee t o f i l e a
compl ai nt agai nst her , but t hen r et r act ed her st at ement when t he
I nvest i gat i ve Commi t t ee br ought up anot her compl ai nt f i l ed by
Ms. Fer nandez. Ms. Sul l i van st at ed, " I apol ogi ze. I don' t l ook
at t hi s commi t t ee as a r eal cour t house, and so t her ef or e I
232
Depar t ment of Heal t h, Document s r el at i ng t o Resul t s of t he Empl oyee
I nci dent Repor t f i l ed by J ayl i ng Fer nandez ( LR_092914_4_1- 3 Conf i dent i al ) .
233
234
235
236
Depar t ment of Heal t h, Document s r el at i ng t o t he Cur r ent St at us of t he
Empl oyee I nci dent Repor t f i l ed by J ayl i ng Fer nandez ( LR_092914_5_1- 4

f or got t hat I was under oat h. "
237
ext r emel y di sappoi nt ed t hat Ms. Sul l i van does not t ake t he
pur pose of t hi s i nvest i gat i on ser i ousl y and does not appr eci at e
her di smi ssi ve at t i t ude. The I nvest i gat i ve Commi t t ee
cont empl at es whet her she exer ci ses t hi s same at t i t ude when
car r yi ng out her dut i es as a Nur se Manager and l i st eni ng and
appr opr i at el y r espondi ng t o t he needs her st af f i n a r espect f ul ,
pr of essi onal , and f ai r manner . Fur t her mor e, t he I nvest i gat i ve
Commi t t ee wonder s how many compl ai nt s woul d be f i l ed agai nst Ms.
Sul l i van i f empl oyees wer e not f ear f ul of r et al i at i on by her or
ot her Hospi t al admi ni st r at or s.

237
Test i mony of Candace Sul l i van, Sept ember 16, 2014.

PART IV.
CONCLUSIONS OF THE SENATE SPECIAL INVESTIGATIVE COMMITTEE

The Hospi t al has a dut y of car e not onl y t o i t s pat i ent s,
but t o t hei r st af f who car e f or t he pat i ent s. I t appear s t o t he
I nvest i gat i ve Commi t t ee t hat t he Hospi t al f aces l ongst andi ng
chal l enges t hat i mpact t he per sonal saf et y and wor k envi r onment
of Hospi t al empl oyees. These chal l enges per si st despi t e pr i or
f eder al , execut i ve, and l egi sl at i ve i nt er vent i on.

Af t er l i st eni ng t o many t est i f i er s over t he cour se of t he
i nvest i gat i on and af t er r evi ewi ng wel l over a t housand pages of
subpoenaed document s, t he I nvest i gat i ve Commi t t ee has deep
concer ns r egar di ng r epor t s of vi ol ent and unst abl e pat i ent s
at t acki ng st af f and causi ng ser i ous i nj ur i es t o t he st af f . The
I nvest i gat i ve Commi t t ee i s concer ned t hat i f t hi s pr obl emi s not
i mmedi at el y addr essed, a f at al i t y wi l l occur at t he Hospi t al .
The I nvest i gat i ve Commi t t ee i s al so concer ned t hat t he
per si st ent l y hi gh pat i ent census f or ces t he Hospi t al t o st r et ch
i t s l i mi t ed r esour ces t o danger ousl y t hi n l evel s, whi ch
compr omi ses pat i ent and st af f saf et y. Last l y, t he I nvest i gat i ve
Commi t t ee i s concer ned about t he st af f i ng and st af f per f or mance
at t he Hospi t al and how t hese i ssues ul t i mat el y i mpact pat i ent
car e.

I n l i ght of t hese l ongst andi ng chal l enges, t he Hospi t al
cannot cont i nue t o mai nt ai n oper at i ons at t he st at us quo. The
Hospi t al and t he Depar t ment of Heal t h woul d benef i t f r omgai ni ng
a br oader per spect i ve and ut i l i zi ng addi t i onal r esour ces f or
i nf or mat i on and gui dance t o make t he necessar y changes so t hat
i t can successf ul l y achi eve i t s mi ssi on.

PART V.
RECOMMENDATIONS OF THE SENATE SPECIAL INVESTIGATIVE COMMITTEE

The I nvest i gat i ve Commi t t ee has i dent i f i ed var i ous
shor t comi ngs r el at i ng t o t he Hospi t al ' s ef f or t s i n mai nt ai ni ng a
saf e wor k envi r onment , usi ng i t s f aci l i t i es, and i mpl ement i ng
ef f i ci ent and t r anspar ent human r esour ces pr act i ces. I n l i ght
of t hese l ongst andi ng chal l enges f aci ng t he Hospi t al , i t i s
cl ear t hat f ur t her act i on i s r equi r ed t o addr ess t he pr obl ems at
t he Hospi t al . The Depar t ment of Heal t h and t he Hospi t al must
enact f undament al changes t han have been di scussed and
r ecommended i n t he past .

The I nvest i gat i ve Commi t t ee not es t hat dur i ng t he cour se of
i t s i nvest i gat i on, a new Hospi t al Admi ni st r at or , Wi l l i amMay,
has been hi r ed and t he Act i ng Admi ni st r at or , Wi l l i amEl l i ot t ,
r et i r ed. The I nvest i gat i ve Commi t t ee engaged i n a t hought f ul
di scussi on wi t h Mr . May r egar di ng hi s exper i ence and pl ans f or
t he Hospi t al .
238
Dur i ng t hi s di scussi on, Mr . May i dent i f i ed f our
pr obl emar eas t hat he has obser ved si nce comi ng on boar d on
J ul y 7, 2014: ( 1) t he physi cal l ayout of t he Hospi t al ; ( 2) hi gh
pat i ent census; ( 3) Hospi t al st af f i ng; and ( 4) Hospi t al
saf et y.
239
Mr . May not ed t hat t hese chal l enges ar e r el at ed t o
each ot her and can of t en be f ound nat i onwi de i n ot her ment al
heal t h f aci l i t i es.
240
The I nvest i gat i ve Commi t t ee not es t hat i t s
f i ndi ngs ar e si mi l ar and r el at ed t o al l f our pr obl emar eas Mr .
May i dent i f i ed, whi ch pr ovi des t he I nvest i gat i ve Commi t t ee wi t h
some assur ance t hat f undament al changes may be possi bl e.

Accor di ngl y, t he I nvest i gat i ve Commi t t ee pr ovi des t he
f ol l owi ng r ecommendat i ons t o t he Hospi t al and Depar t ment of
Heal t h i n an ef f or t t o assi st t hose ent i t i es i n r esol vi ng t he
shor t comi ngs f aced by t he Hospi t al . To f ost er a f r amewor k f or
change, t he I nvest i gat i ve Commi t t ee r equest s t hat t he Hospi t al
submi t a wr i t t en r epor t t o t he Legi sl at ur e pr ovi di ng t he st at us
of i t s ef f or t s i n i mpl ement i ng t he f ol l owi ng r ecommendat i ons no
l at er t han 20 days pr i or t o t he conveni ng of Regul ar Sessi on of
2015 and Regul ar Sessi on of 2016.

Wi t h r egar d t o mai nt ai ni ng a saf e wor k envi r onment , t he
I nvest i gat i ve Commi t t ee bel i eves t hat t he Hospi t al shoul d:

238
239
240

1. Devel op st andar di zed r ecor di ng pr ocedur es t o
accur at el y r epor t assaul t s occur r i ng at t he Hospi t al .
Speci f i cal l y:

a. Devel op dat a gat her i ng and anal ysi s pr ocedur es
t hat :

i . I dent i f y t he per pet r at or and vi ct i mof t he
assaul t ;

i i . I dent i f y t he pat i ent event r epor t number ,
empl oyee i nci dent r epor t number , or acci dent
r epor t number ;

i i i . Descr i be t he assaul t ;

i v. Cat egor i ze any r esul t i ng i nj ur y of t he
assaul t ;

v. I ndi cat e t he di sposi t i on of t he assaul t ; and

vi . I ndi cat e any ot her i nf or mat i on t hat wi l l
enabl e t he Hospi t al t o bet t er t r ack t he
number of assaul t s occur r i ng at t he
Hospi t al ;

b. Devel op and i mpl ement st andar d def i ni t i ons and
cat egor i es f or at t empt ed assaul t , assaul t , and
ser i ous assaul t t hat i ncl ude and descr i be t he
l evel of any r esul t i ng i nj ur y;

c. Devel op and i mpl ement st andar d def i ni t i ons and
cat egor i es f or t he t ypes of i nj ur i es t hat may
r esul t f r oman assaul t t o assi st i n det er mi ni ng
whet her an assaul t i s an at t empt ed assaul t ,
assaul t , or ser i ous assaul t ;

d. Revi se and st r engt hen pol i ci es and pr ocedur es
t hat mandat e empl oyees t o f i l e an empl oyee
i nci dent r epor t f or ever y event t hat occur s and
ensur e t hat t hese pol i ci es and pr ocedur es ar e
i mpl ement ed by al l empl oyees;

e. Revi se and st r engt hen pol i ci es and pr ocedur es
r egar di ng wor ker s' compensat i on and col l abor at e
wi t h t he Depar t ment of Labor and I ndust r i al
Rel at i ons t o expedi t e t he f i l i ng, appr oval , and
payment of wor ker s' compensat i on cl ai ms; and

f . I mpr ove communi cat i on bet ween Hospi t al
admi ni st r at or s and Depar t ment of Heal t h
admi ni st r at or s r egar di ng r epor t s of assaul t s
occur r i ng at t he Hospi t al t o ensur e t hat
Depar t ment admi ni st r at or s can obt ai n a f ul l scope
of t he pr obl em;

2. Educat e and t r ai n al l empl oyees on wor kpl ace vi ol ence,
especi al l y wi t h r egar d t o t he pol i ci es and pr ocedur es
t o r epor t i nci dent s of wor kpl ace vi ol ence and
empl oyees' opt i ons i f t hey ar e t he vi ct i mof such
vi ol ence;

3. Devel op and i mpl ement a per vasi ve and appr opr i at e
t r ai ni ng pr ogr amf or empl oyees t o handl e f or ensi c
ment al heal t h pat i ent s. Speci f i cal l y:

a. Expl or e any best pr act i ces or empl oyee t r ai ni ng
pr ogr ams on handl i ng f or ensi c ment al heal t h
pat i ent s f r omsi mi l ar ment al heal t h f aci l i t i es i n
ot her j ur i sdi ct i ons t hat t r eat f or ensi c ment al
heal t h pat i ent s;

b. Expl or e and det er mi ne t he f easi bi l i t y of
i ncor por at i ng any t ype of t r ai ni ng pr ogr ams t hat
ar e si mi l ar t o t he t r ai ni ng cor r ect i onal of f i cer s
r ecei ve i n handl i ng i ncar cer at ed i ndi vi dual s;

c. Of f er and r equi r e empl oyees t o at t end t r ai ni ng
pr ogr ams on handl i ng f or ensi c ment al heal t h
pat i ent s mor e t han once a year ; and

d. Expl or e t he f easi bi l i t y of hi r i ng addi t i onal
secur i t y of f i cer s on campus t o assi st wi t h
moni t or i ng pat i ent s and r espondi ng t o emer gency
si t uat i ons and secur i t y br eaches wi t hi n t he
Hospi t al ; and

4. Addr ess and r esol ve t he HI OSH vi ol at i ons
241
ci t ed on
Apr i l 10, 2014, and col l abor at e wi t h t he Depar t ment of
Labor and I ndust r i al Rel at i ons t o ai d i n st r engt heni ng
i t s pol i ci es and pr ocedur es t o cr eat e a saf e wor kpl ace
envi r onment .

Wi t h r egar d t o usi ng f aci l i t i es and exer ci si ng saf et y
pr act i ces ef f i ci ent l y, t he I nvest i gat i ve Commi t t ee bel i eves t hat
t he Hospi t al shoul d:
241

1. Devel op and i mpl ement a pat i ent cl assi f i cat i on syst em
t hat i s based on pat i ent need. Speci f i cal l y:

a. Expl or e any pat i ent cl assi f i cat i on syst ems t hat
ar e used by si mi l ar ment al heal t h f aci l i t i es i n
ot her j ur i sdi ct i ons, especi al l y f aci l i t i es wi t h
f or ensi c ment al heal t h pat i ent s;

b. Anal yze and det er mi ne t he i mpact a pat i ent
cl assi f i cat i on syst emmay have on pat i ent car e
and st af f r at i os;

c. I f necessar y, consul t wi t h t he appl i cabl e l abor
uni ons r egar di ng how a pat i ent cl assi f i cat i on
syst emmay i mpact col l ect i ve bar gai ni ng
agr eement s; and

d. Anal yze and det er mi ne t he i mpact t hat a pat i ent
cl assi f i cat i on syst emmay have on t he exi st i ng
Hospi t al f aci l i t i es and t he abi l i t y of t he
exi st i ng f aci l i t i es i n accommodat i ng a pat i ent
cl assi f i cat i on syst em;

2. Consi der opt i ons i n desi gnat i ng Uni t H sol el y f or t he
pur pose of admi t t i ng pat i ent s. Speci f i cal l y:

a. Expl or e best pr act i ces at si mi l ar ment al heal t h
f aci l i t i es r egar di ng separ at i ng t he admi ssi ons
uni t f r omot her uni t s;

b. Det er mi ne t he f easi bi l i t y of shar i ng admi ssi on
r esponsi bi l i t i es wi t h Uni t F t o i ncr ease t he
number of avai l abl e beds f or admi t t ed pat i ent s
and t he i mpact t he shar i ng of admi ssi on
r esponsi bi l i t i es bet ween Uni t s H and F wi l l have
on t he ot her uni t s;

c. Consul t wi t h t he appl i cabl e l abor uni ons
r egar di ng how desi gnat i ng Uni t H f or admi ssi ons
onl y or shar i ng admi ssi on r esponsi bi l i t i es wi t h
Uni t F may i mpact col l ect i ve bar gai ni ng
agr eement s; and

d. Col l abor at e wi t h t he Depar t ment of Publ i c Saf et y
and t he J udi ci ar y t o i mpr ove and st r engt hen
communi cat i on and t he shar i ng of i nf or mat i on wi t h
r espect t o t he st at us of pat i ent s who ar e
t r ansf er r ed t o t he Hospi t al pur suant t o a cour t
or der t o enabl e t he Hospi t al t o bet t er pl an,
pr epar e, and pr ovi de f or pat i ent s bei ng
t r ansf er r ed and admi t t ed t o t he Hospi t al f or
eval uat i on and t r eat ment ;

3. Consi der obt ai ni ng a f or ensi c car e desi gnat i on or
accr edi t at i on f or t he Hospi t al . Speci f i cal l y:

a. Expl or e ment al heal t h f aci l i t i es i n ot her
j ur i sdi ct i ons t hat have a f or ensi c ment al heal t h
desi gnat i on or accr edi t at i on t o anal yze t he pr os
and cons of havi ng such a desi gnat i on and
accr edi t at i on f or t he Hospi t al ;

b. Det er mi ne t he i mpact t hat a f or ensi c ment al
heal t h desi gnat i on or accr edi t at i on may have on
t he Hospi t al ; and

c. Col l abor at e wi t h t he Depar t ment of Publ i c Saf et y
t o expl or e and devel op l ong- t er mst r at egi es f or
t he Depar t ment of Publ i c Saf et y t o est abl i sh a
f or ensi c ment al heal t h uni t at t he pr i sons t o
r educe t he number of f or ensi c ment al heal t h
pat i ent s bei ng admi t t ed t o t he Hospi t al ;

4. Faci l i t at e t he t r ansf er of hi gh r i sk pat i ent s t o out -
of - st at e ment al heal t h f aci l i t i es cont r act ed wi t h t he
St at e by sel ect i ng pat i ent s t hat may qual i f y and
benef i t f r ombei ng t r ansf er r ed per t he newl y adopt ed
pol i ci es and pr ocedur es and det er mi ne whet her such
pat i ent s shoul d be t r ansf er r ed;

5. Addr ess t he saf et y concer ns and cl osur e of t he PI CU.
Speci f i cal l y:

a. Addr ess t he saf et y concer ns of t he PI CU by
expedi t i ng t he ongoi ng consul t at i ons wi t h HGEA
and UPW; and

b. Expl or e and det er mi ne t he f easi bi l i t y of
al t er nat i ve uses f or t he PI CU;

6. Expl or e and devel op shor t - t er mst r at egi es f or t he
physi cal i mpr ovement and r enovat i on of t he exi st i ng
Hospi t al f aci l i t y. Speci f i cal l y:

a. Assess and pr i or i t i ze t he ar eas of t he Hospi t al
t hat need i mpr ovement , upgr ade, r epai r , or
r epl acement , and est abl i sh a f easi bl e t i mel i ne
f or t he compl et i on of t hese pr oj ect s;

b. Expl or e desi gn opt i ons by consi der i ng t he desi gns
of f or ensi c ment al heal t h f aci l i t i es i n ot her
j ur i sdi ct i ons t o bet t er meet t he needs of
f or ensi c ment al heal t h pat i ent s and t he st af f who
pr ovi de pat i ent car e, as wel l as t o addr ess t he
Hospi t al ' s secur i t y needs;

c. Expl or e addi t i onal f undi ng mechani sms t o suppor t
t he r epai r and i mpr ovement of t he exi st i ng
f aci l i t y, and r equest addi t i onal f undi ng f r omt he
Legi sl at ur e, i f necessar y;

d. Anal yze and det er mi ne t he i mpact of any r epai r
and i mpr ovement pr oj ect s on pat i ent car e and
st af f - t o- pat i ent r at i os; and

e. I f necessar y, consul t wi t h t he appl i cabl e l abor
uni ons r egar di ng how any r epai r and i mpr ovement
pr oj ect s may i mpact col l ect i ve bar gai ni ng
agr eement s;

7. Expl or e and devel op l ong- t er mst r at egi es f or t he
desi gn and const r uct i on of a new f aci l i t y.
Speci f i cal l y:

a. Det er mi ne t he f easi bi l i t y of bui l di ng a new
f aci l i t y or r enovat i ng and upgr adi ng t he exi st i ng
f aci l i t y;

b. Expl or e addi t i onal f undi ng mechani sms t o suppor t
t he demol i t i on of t he exi st i ng f aci l i t y, i f
appr opr i at e, and desi gn, const r uct i on, and
mai nt enance of a new f aci l i t y; and

c. Expl or e desi gn opt i ons by consi der i ng t he desi gns
of f or ensi c ment al heal t h f aci l i t i es i n ot her
j ur i sdi ct i ons t o bet t er meet t he needs of
f or ensi c ment al heal t h pat i ent s and t he st af f who
pr ovi de pat i ent car e, as wel l as t o addr ess t he
Hospi t al ' s secur i t y needs;

8. I mpr ove t he moni t or i ng and oper at i on of t he secur i t y
camer as. Speci f i cal l y:

a. Revi se pol i ci es and pr ocedur es t o i ncr ease t he
number of secur i t y of f i cer s t o di vi de t he dut i es
associ at ed wi t h moni t or i ng t he secur i t y camer as;
and

b. Ensur e t hat al l secur i t y camer as ar e oper at i ng at
al l t i mes and devel op pol i ci es and pr ocedur es t o
r out i nel y check t he oper at i on of al l camer as;

9. I mpr ove t he PMT devi ces t o ensur e t hat t he devi ces
wor k pr oper l y at al l t i mes. Speci f i cal l y:

a. Upgr ade t he PMT devi ces t o ensur e t hat t he
devi ces wor k pr oper l y at al l t i mes and accur at el y
t r ansmi t t he l ocat i on of a Code 200;

b. St r engt hen and i mpl ement pol i ci es and pr ocedur es
t o ensur e t hat st af f r espond when a Code 200 i s
t r ansmi t t ed; and

c. Requi r e t hat al l PMT devi ces ar e r out i nel y
i nspect ed f or pr oper oper at i on;

10. Expl or e t he f easi bi l i t y of const r uct i ng a f ence ar ound
t he per i met er of t he campus t o ensur e saf et y f or t he
sur r oundi ng communi t y and assi st i n pr event i ng
el opement s. Speci f i cal l y:

a. Expl or e di f f er ent t ypes of f enci ng opt i ons t o
encl ose t he ent i r e campus or par t s of t he campus;
and

b. Request addi t i onal f undi ng f r omt he Legi sl at ur e,
i f necessar y, f or const r uct i on; and

11. Devel op pr ocedur es t o al er t t he communi t y when a
pat i ent el opement occur s. Speci f i cal l y:

a. Revi se pol i ci es and pr ocedur es t o est abl i sh when
HPD i s t o be not i f i ed of a pat i ent el opement so
t hat HPD may assi st i n t he sear ch ef f or t s; and

b. Devel op and i mpl ement pol i ci es and pr ocedur es t o
al er t t he st udent s and st af f at Wi ndwar d
Communi t y Col l ege of a pat i ent el opement .

Wi t h r egar d t o pr ovi di ng ef f i ci ent and ef f ect i ve human
r esour ces pr act i ces, t he I nvest i gat i ve Commi t t ee bel i eves t hat
t he Hospi t al shoul d:

1. St r eaml i ne and consol i dat e t he Hospi t al ' s and
Depar t ment of Heal t h' s i nt er nal r ecr ui t ment and hi r i ng
pr ocesses t o expedi t e t he f i l l i ng of posi t i on
vacanci es at t he Hospi t al . Speci f i cal l y:

a. Det er mi ne whi ch st eps i n t he Hospi t al ' s and
Depar t ment ' s i nt er nal r ecr ui t ment and hi r i ng
pr ocesses may be st r eaml i ned or consol i dat ed t o
cr eat e a mor e ef f i ci ent and expedi t i ous pr ocess;

b. Col l abor at e wi t h t he Depar t ment of Human
Resour ces Devel opment i n st r eaml i ni ng and
consol i dat i ng t he st eps i n t he i nt er nal
r ecr ui t ment and hi r i ng pr ocesses t o ensur e
adher ence t o al l appl i cabl e hi r i ng l aws and
r ul es; and

c. Expl or e opt i ons i n i mpr ovi ng t he i nt er nal
r ecr ui t ment and hi r i ng pr ocesses t o expedi t e t he
f i l l i ng of posi t i on vacanci es at t he Hospi t al ;

2. Devel op pol i ci es and pr ocedur es r egar di ng t he
r ecr ui t ment of t empor ar y agency wor ker s.
Speci f i cal l y:

a. Col l abor at e wi t h t he Depar t ment of Human
Resour ces Devel opment t o ensur e such pol i ci es
adher e t o appl i cabl e l aws and r ul es; and

b. Est abl i sh a pol i cy t o pr ohi bi t t he Hospi t al f r om
pr ovi di ng names of i ndi vi dual s t o t he t empor ar y
empl oyment agenci es t o wor k at t he Hospi t al ;

3. St r engt hen t he pol i ci es and pr ocedur es f or
i nt er vi ewi ng and hi r i ng empl oyees t o wor k at t he
Hospi t al . Speci f i cal l y:

a. Devel op and i mpl ement a pol i cy and pr ocedur e
r egar di ng t he empl oyment of r el at i ves of cur r ent
st af f t o r educe al l egat i ons of f avor i t i smand
nepot i sm;

b. Devel op and i mpl ement pol i ci es and pr ocedur es t o
ensur e t hat t he i nt er vi ew pr ocess i s f r ee f r om
conf l i ct s of i nt er est and r equi r e di scl osur e and
r ecusal of i nt er vi ew panel i st s i f a conf l i ct of
i nt er est exi st s;

c. Col l abor at e wi t h t he Depar t ment of Human
Resour ces Devel opment t o ensur e t hat such
pol i ci es and pr ocedur es adher e t o appl i cabl e l aws
and r ul es; and

d. Consul t wi t h t he Hawai i St at e Et hi cs Commi ssi on
t o ensur e t hat such pol i ci es and pr ocedur es
adher e t o and ar e consi st ent wi t h t he St at e' s
Code of Et hi cs;

4. Devel op and i mpl ement pr ocedur es f or t he assi gnment of
over t i me. Speci f i cal l y:

a. Est abl i sh wr i t t en pol i ci es and pr ocedur es
r egar di ng t he assi gnment of over t i me and ensur e
t hat such pr ocedur es ar e consi st ent l y f ol l owed;

b. Expedi t e t he i nst al l at i on of t he Kr onos comput er
syst emt o assi st i n t he assi gnment of over t i me;
and

c. I f necessar y, consul t wi t h t he appl i cabl e l abor
uni ons r egar di ng how t he assi gnment of over t i me
may i mpact col l ect i ve bar gai ni ng agr eement s;

5. Expl or e opt i ons t o l i mi t t he number of over t i me shi f t s
or hour s an empl oyee may per f or m. Speci f i cal l y:

a. Expl or e how ot her st at e agenci es or si mi l ar
ment al heal t h f aci l i t i es i n ot her j ur i sdi ct i ons
have successf ul l y r educed or l i mi t ed over t i me;
and

b. Devel op and i mpl ement pol i ci es and pr ocedur es
r egar di ng per f or mi ng back- t o- back shi f t s;

6. Cont r ol t he oppor t uni t i es f or empl oyees t o abuse si ck
l eave and over t i me benef i t s. Speci f i cal l y:

a. Expl or e t he opt i ons t o r educe t he number of
consecut i ve days of si ck l eave af t er whi ch an
empl oyee i s r equi r ed t o submi t a doct or ' s not e or
r equi r e a 24- hour wai t i ng per i od bef or e an
empl oyee who i s back f r omsi ck l eave may per f or m
an over t i me shi f t ; and

b. Consul t wi t h t he appl i cabl e l abor uni ons t o
ensur e t hat col l ect i ve bar gai ni ng agr eement s ar e
f ol l owed;

7. Col l abor at e wi t h t he appr opr i at e l abor uni ons t o
addr ess t he i mpact t hat col l ect i ve bar gai ni ng
agr eement s have on over t i me benef i t s;

a. Di scuss and devel op al t er nat i ve opt i ons t o amend
col l ect i ve bar gai ni ng agr eement s t o pl ace l i mi t s
on t he amount of over t i me an empl oyee may
per f or m;

b. Di scuss and devel op opt i ons t o addr ess t he Konno
deci si on and t he i mpact t hat i t has on assi gni ng
over t i me shi f t s t o ci vi l ser vi ce empl oyees; and

c. I nt r oduce l egi sl at i on pr oposed by t he Depar t ment
of t he At t or ney Gener al
242
t hat pr ovi des an
exempt i on f r omt he appl i cabi l i t y of Konno
243
f or
st at e i nst i t ut i ons wi t h 24- hour s- a- day, seven-
days- a- week st af f i ng r esponsi bi l i t i es by usi ng
pr i vat e st af f i ng cont r act or s t o al l evi at e day- t o-
day st af f i ng shor t ages wi t hout havi ng t o f i r st
of f er over t i me oppor t uni t i es t o ci vi l ser vi ce
st af f ( See, At t achment A) ; and

8. St r engt hen and i mpl ement pol i ci es and pr ocedur es
r egar di ng empl oyee compl ai nt s and di sci pl i nar y
act i ons. Speci f i cal l y:

a. Devel op and i mpl ement pol i ci es and pr ocedur es t o
assur e t hat an empl oyee compl ai nt i s handl ed i n a
f ai r and t r anspar ent manner , i ncl udi ng keepi ng
t he compl ai ni ng empl oyee i nf or med of t he st at us
and out come of t he compl ai nt ;

b. Devel op and i mpl ement pol i ci es and pr ocedur es
r egar di ng per mi ssi bl e and pr ohi bi t ed conduct
whi l e a compl ai nt i s open and under
i nvest i gat i on;

c. St r engt hen pol i ci es and pr ocedur es t o ensur e t hat
an empl oyee agai nst whoma compl ai nt i s f i l ed i s
pr ovi ded due pr ocess;

242
243

d. Consul t wi t h t he appl i cabl e l abor uni ons t o
ensur e t hat any pol i ci es and pr ocedur es r egar di ng
empl oyee i nvest i gat i ons adher e t o col l ect i ve
bar gai ni ng agr eement s; and

e. Col l abor at e wi t h t he Depar t ment of t he At t or ney
Gener al t o ensur e t hat any pol i ci es and
pr ocedur es r egar di ng empl oyee i nvest i gat i ons
adher e t o pr i vacy l aws and appl i cabl e empl oyment
pr act i ces.

The I nvest i gat i ve Commi t t ee r ecommends t he Legi sl at ur e t ake
t he f ol l owi ng act i on on dur i ng t he Regul ar Sessi on of 2015:

1. I nt r oduce l egi sl at i on r equest i ng t he St at e Audi t or
conduct a management audi t of t he Hospi t al ;

2. I nt r oduce l egi sl at i on pr oposed by t he Depar t ment of
t he At t or ney Gener al
244
t hat pr ovi des an exempt i on f r om
t he appl i cabi l i t y of Konno
245
f or st at e i nst i t ut i ons
wi t h 24- hour s- a- day, seven- days- a- week st af f i ng
r esponsi bi l i t i es by usi ng pr i vat e st af f i ng cont r act or s
t o al l evi at e day- t o- day st af f i ng shor t ages wi t hout
havi ng t o f i r st of f er over t i me oppor t uni t i es t o ci vi l
ser vi ce st af f ( See, At t achment A) ; and

3. Consi der t he i nf usi on of addi t i onal f unds and
addi t i onal f undi ng r esour ces t o assi st t he Hospi t al i n
i t s ef f or t s t o addr ess and r esol ve t he pr obl emar eas
i dent i f i ed i n t hi s Repor t by t he I nvest i gat i ve
Commi t t ee.

244
245

APPENDIX A
APPENDIX B
APPENDIX C

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PART I.

INTRODUCTION HAWAII STATE HOSPITAL

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