Chaotic conditions in Georgia's state mental hospitals threaten the safety of patients and employees alike.

Corridors are so volatile at one hospital that doctors and nurses sedate patients with Benadryl and other drugs just to maintain control. Still, employees of all seven state hospitals claim more injuries from altercations with patients than from all other causes combined.

Staffing is so thin and budgets so tight that employees often work double shifts: 16 hours straight, with no overtime pay. With starting salaries for technicians as low as $18,000, many could earn more working at Wal-Mart.

The hospitals are so crowded that a single registered nurse may care for 30 or more patients at once.

"It's terribly understaffed and extremely dangerous," says Virgil Wells, a former health services technician at Georgia Regional Hospital/Atlanta who describes a battleground atmosphere. "I've seen patients go after each other, go after nurses, physically attack [technicians]. The nurses are overwhelmed."

Johnnie Eason, a nurse who is contesting her dismissal from the Atlanta hospital in a dispute over a patient's improper seclusion, says: "I don't see how the hospital stays open. Morale is very low. The patients are very difficult. Often they have drug and alcohol problems. They have many demands. They get agitated."

Georgia officials acknowledge problems identified in The Atlanta Journal-Constitution's examination of the state hospitals. But for most of this decade, they have taken what appears to be a counterintuitive approach: cutting the hospitals' budgets, thereby exacerbating conditions that have contributed to the suspicious deaths of at least 115 patients since 2002, the newspaper found.

Many of the suspicious deaths involved neglect: Patients choked on food or vomit. They committed suicide. They died from a lack of emergency treatment or from long-term substandard care.

Improving the hospitals would require a combination of quick-fix and long-term measures, according to a dozen psychiatrists, medical school professors and mental health advocates interviewed by the Journal-Constitution.

Those experts say state officials could make immediate progress by addressing the hospitals' most basic problem: too many patients, not enough caretakers.

"As I look at this evidence, there are a surprising number of cases where we could wonder about the lack of adequate medical care and nursing care," says Dr. Alfred Herzog, chairman of the American Psychiatric Association's patient safety committee and medical director of professional programs at a private mental hospital in Hartford, Conn.

The Georgia Department of Human Resources, which operates the hospitals, is shifting resources to community-based services in hopes of reducing hospital admissions. B.J. Walker, the state's human resources commissioner, says she has no plans to seek more money for hospitals.

"If you try to solve it by making it a simple issue of dollars and cents and numbers, we will not have a good behavioral health system," Walker says. "My job as a public official is to take the dollars I'm given" and spend them appropriately.

She acknowledges, however, that the state also has cut funding for community mental health boards, which provide many of the alternative services. She says she has instead boosted treatment programs for mentally ill children.

Staff 'burned out'

Georgia ranks 44th in the nation in spending per resident on mental health care, and has languished near the bottom for years, regardless of which political party has controlled state government. The hospitals rarely get attention from state legislators unless bureaucrats propose reducing the size of the facilities — key employers in such small cities as Milledgeville, Thomasville and Rome.

Since the 2004 fiscal year, the hospitals' operating budgets — which include state and federal money — have declined by 12 percent. But the average daily number of adult mental health patients will have risen about 12 percent by the end of this fiscal year, officials project.

The average occupancy rate in those units was 109 percent during the past fiscal year — about 60 more patients than beds. The hospitals have almost 2,700 beds in units for adults, adolescents, people with developmental disabilities and forensic patients placed by the courts.

Shrinking budgets have squeezed hospitals.

In a letter to employees last February, Ronald Hogan, administrator of Georgia Regional in Atlanta, said that despite the budget cuts, the facility would maintain "a work force with numbers that are minimally sufficient to operate and execute our business in an ethical manner."

In another letter in April, however, Hogan wrote, "Our budgetary cuts ... have seriously impacted our operations."

Because of the cuts, one registered nurse, perhaps assisted by a licensed practical nurse and four or five technicians, may have responsibility for 30, 40 or more patients at a time, staffing records indicate. The American Psychiatric Nurses Association generally recommends one registered nurse for every six to 10 patients.

During an overnight shift at the Atlanta hospital last Feb. 12, one nurse was responsible for the care of 22 adolescent patients, for admitting new patients, for administrative duties and for responding to emergencies throughout the facility. That night, amid what another nurse described as "chaos," a 14-year-old girl, Sarah Elizabeth Crider, died from a bowel obstruction.

In April 2006, according to inspection reports reviewed by the Journal-Constitution, one adult unit at the Atlanta hospital was overcapacity 29 of 30 days. Such crowding can force four to five patients to squeeze into a space no larger than an average living room.

Also during April, the same adult unit had no more than two nurses assigned to 75 of 90 work shifts, and five or fewer technicians on 77 shifts.

Hospital employees say such situations inevitably lead to poor care. High staff turnover, they say, creates further problems, but is hardly surprising.

After starting as low as $18,000, salaries for health services technicians rarely exceed $25,000. Registered psychiatric nurses start at about $31,000 — far less than at private hospitals and 28 percent less than at the state Department of Corrections, according to a 2005 analysis.

"We have staff that are burned out," says Dr. George Negron, a psychiatrist at Georgia Regional Hospital/Savannah. "They are very, very frustrated."

Adds Dr. Gary Carter, a psychiatrist at Southwestern State Hospital in Thomasville: "Any time you get overcrowding, the care will slip."

Culture of violence

During a routine review at Central State Hospital in Milledgeville last summer, state and federal inspectors discovered a culture of violence on a unit with patients who are mentally retarded.

From April to July, the inspectors said, 45 of the unit's 84 patients sustained injuries in assaults by other patients. Some were injured two or three times.

The newspaper found similar disorder throughout the mental hospital system.

At the Atlanta hospital, the medical staff has routinely dispensed the antihistamine Benadryl and other drugs to control patients. "Sedation appears to be a desired effect of medication rather than an unwanted side effect," a recent state report said.

But without such "oversedation," the report concluded, "there is a high probability that safety ... will be compromised." State officials, when questioned last week on the medication issue, said the problem "has been addressed."

Still, staff injuries are an everyday occurrence.

An analysis by the Journal-Constitution of state workers' compensation claims found that altercations with patients accounted for more than 2,700 cases, or 54 percent, filed at the state hospitals from July 2002 through June 2006. Settling those claims has cost $3.3 million, with more cases pending. In 2005, for example, the state paid $52,038 for medical bills and lost wages of an employee at Central State who received head and neck injuries when a patient struck him several times in the head with a sock containing a billiard ball.

Although abuse of patients by hospital workers is well established, numerous instances exist of abuse in reverse.

In one case, two employees at the Atlanta hospital said a patient sexually assaulted them in separate incidents an hour apart. Hospital officials moved the patient to another unit, and one of the employees, Angela Shuttlesworth, went to court seeking a warrant for his arrest. By the time a court hearing took place, the hospital had discharged the patient. He did not appear at the hearing, and a judge issued a warrant for his arrest.

That was last May 19. Now, Shuttlesworth says, "we don't know where he is."

Persistent problems

In 2002, federal regulators demanded that the Atlanta hospital correct severe overcrowding and patient care problems. When regulators returned in 2006, they found many of the same failings depriving patients of needed therapy.

The regulators, who declined to comment for this article, documented as many as 20 patients at a time in a common room, watching television or pacing. Employees were occupied trying to prevent fights among patients.

The report described a tumultuous scene.

"Change — just a quarter," one patient said to anyone entering the common room, according to the report. "I'm not asking for a handout."

Another patient draped a handkerchief over his head and paced rapidly back and forth across the room. A woman yelled, "I don't belong here, I'm being held against my will," while another emerged from her room half-naked.

A man who had been in the hospital four days told the regulators he had received no treatment and had spent his time "sitting and reading, watching movies, watching TV." He told them he was more depressed than when he entered the hospital.

Between the 2002 and 2006 inspections, the Journal-Constitution determined, 18 patients at the Atlanta hospital died under suspicious circumstances. One more patient died after the latest inspection.

Despite such persistent problems, experts in psychiatric care say sweeping improvements are possible — but require political will, leadership and money.

"Ultimately, do the taxpayers want to do what's needed to be done in their state hospitals, or not?" says Dr. Jeffrey Geller, director of public sector psychiatry at the University of Massachusetts Medical School.

"It's too simplistic to make the state hospital the isolated villain," he says. "The state hospital is as much a victim as a villain — a victim of inadequate funding, a victim of the general population of the state not caring enough about its most unfortunate and disenfranchised, a victim of ineffective utilization of resources that do exist."