Chad Taylor is risking a lot by coming forward.
But the former Arizona State Hospital employee believes the public needs to know the truth about problems that plague our state’s only publicly-run mental health facility.
He’s also revealing troubling new details about a patient’s death.
“I’m risking never being able to work in the field again,” Taylor said. “But that should also let you know how strongly I feel about what’s going on there, and how bad I want things to change.”
Taylor has worked in behavioral health for 15 years. Last month, he resigned from his position as a direct-care staff supervisor after spending one year working at the hospital with patients on both the civil and forensic unit.
“This is the worst, most dysfunctional facility I have ever worked at,” Taylor said. “It’s like playing Russian roulette. A lot of staff members just hope and pray that nothing transpires on their shift.”
ABC15 has been investigating the Arizona State Hospital, or ASH, for more than two years. ASH treats roughly 230 patients and is a last resort for the state’s severely mentally ill and criminally insane. We’ve spoken to dozens of insiders and reviewed thousands of pages of records to expose a hospital that deficient, dangerous and deadly.
But despite patient deaths, a failed federal inspection and promises to improve the level of care, Taylor said nothing has changed.
“It’s a ticking-time bomb,” he said. “It’s certainly not safer. That’s administrative spin. We saw a perfect example of that with Chris Blackwell.”
TROUBLING NEW DETAILS IN PATIENT'S DEATH
Patient Chris Blackwell died September 8th last year.
Just 23 years old, Blackwell was supposed to receive around-the-clock care to prevent him from swallowing dangerous objects. ABC15’s investigation uncovered the hospital failed to properly monitor Blackwell and failed to provide him with adequate medical care.
ABC15’s reports prompted a federal inspection, and the state won’t answer questions about Blackwell’s death.
But Chad Taylor will.
“I was there the day he died, the shift he died,” he said.
ABC15 filed a public records request for all of the files and documents related to Blackwell’s death. In response, the hospital released a one-page incident report that gives few details about what happened.
“That’s intentional,” Taylor said. “We’re told, as far as incident reports go, to be as basic as possible.”
The following paragraph is the unedited summary from the incident report.
“Pt in room drinking ensure, noted to collapse on bed Medical Alert initiated,, Code Blue called, CPR initiated. Pt transferred to Maricopa Medical Center. Mother Notified.”
When asked how much of the story the incident report tells about what happened, Taylor said, “none of it.”
What’s missing? Important facts that happened in the days leading up to his death.
Taylor said he and other staff were told by an administrator to stand down when they could have stepped in and saved his life.
A few days before Blackwell collapsed, Taylor saw him start to eat pieces of a broken CD. Taylor said staff was told to let him do it.
“Chris had CDs in his month. There was a code that was called. He hadn’t swallowed them at this point,” Taylor said. “And as staff was trying to take his hand away from his mouth, we were told ‘No, he’s going to swallow them anyway, and we’ll let the medical side of things handle it.’ It was pretty shocking to me.”
But the medical side failed. Records show they never followed up with Blackwell, missing the severe stomach infection that would soon kill him.
Multiple staff members have told ABC15 Blackwell’s death was unnecessary.
“He still should be here today,” Taylor said. “It’s the hospital’s responsibility to provide a safe and therapeutic environment.”
In fact, Blackwell’s autopsy and other medical records show that several foreign objects had been stuck in his digestive path for several months. Blackwell’s mother has filed a lawsuit against the state. That case is ongoing.
‘IT’S GOTTEN WORSE’
After Blackwell’s death, federal inspectors with the Centers for Medicare and Medicaid Services cited and fined the hospital for severe staffing shortages and not-properly monitoring several at-risk patients like Blackwell.
Officials promised to fix their serious deficiencies in order to save the hospital’s certification and millions in federal tax dollars.
“Not only have they not fixed the staffing issues, it’s worse,” Taylor said. “It’s gotten worse.”
Taylor and other employees have told ABC15 that they believe the hospital administration is misrepresenting staffing levels to federal inspectors.
“(They’re) cooking the books,” Taylor said. “I think they are adjusting numbers to suit their needs.”
Multiple sources tell ABC15 it’s still a revolving door at the hospital, leaving the facility with too few workers to provide proper treatment and care.
The state routinely uses temporary workers to fill in the gaps. But the Feds found last year, in many cases, that temporary workers were not qualified or properly trained to work with patients.
To address the situation, ASH officials said they would have staff take quizzes before shifts to make sure they met and understood certain standards of care.
Taylor said to his knowledge that’s not happening either.
“I’ve never seen that take place before,” he said.
When it comes to violence at the hospital, sources say it’s as bad as ever and that it’s too much for the staff to bear.
Taylor said the group of new workers he was hired with proves it.
“There were about 20 to 24 there to start during the week of my orientation,” he said. A year later, how many still worked at the hospital?
“One,” Taylor said. “One out of 20.”
A state spokesperson did not respond to a request to verify this fact or answer other questions related to this story.
Taylor said it’s the administration’s indifference that led him to resign.
“I haven’t seen anyone improve,” he said. “It’s a stagnant facility. It’s a violent environment. The morale of the staff is next to nothing.”
What about the morale of the patients?
“Equally as low,” Taylor said. “They feel unheard, uncared for. And that’s just not what I signed up to do.”
Contact ABC15 Investigator Dave Biscobing at firstname.lastname@example.org.