An Arizona state mental hospital social worker was able to sneak onto the grounds, get into a patient’s room, kiss and embrace the patient before crawling into her bed and removing clothing, according to sources and records obtained by ABC15.
Both the social worker and patient are female.
The patient is extremely vulnerable and has amputated legs, sources said. She was supposed to be on a constant one-to-one watch, which means one staff member is specifically assigned to her.
But the situation, which happened in February 2014, went undetected for nearly two hours.
The incident highlights the state hospital’s repeated inability to properly supervise patients and keep them safe.
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Insiders and patient advocates also said the response to the incident by top officials raises questions of misconduct and a cover-up.
Several members of a hospital oversight board said records related to the incident were initially hidden from them, and officials delayed producing documentation for more than a year.
ABC15 is not naming the social worker, who did not answer requests for comment.
The social worker suffers from mental illness herself, records show.
At the time of this incident, she was on personal leave and was not allowed on hospital grounds until she completed treatment and was cleared to work again, records show.
STATE HOSPITAL’S VERSION OF WHAT HAPPENED
Officials claim there was a camera in the patient’s room but refused to release a copy of the video.
“Pursuant to HIPAA, ADHS cannot release the video because it clearly depicts a patient, and ASH is not able to conceal the patient’s identity in the video,” state officials said in a written statement.
Investigators also said no sex acts occurred, which is something sources have disputed.
ABC15 requested all records related to the internal investigation. The state produced a single email, about one-and-a-half pages in length, to document the incident.
The email was sent a week after the incident from an investigator to hospital CEO Donna Noriega.
Read the internal investigation
According to the hospital’s investigation, “(The social worker) had been off work due to a personal (redacted) issue and had returned without (redacted). She met her supervisor, Veneranda Heffern who escorted her to the Civil parking lot, at about 2 pm, giving her verbal direction to not return to work at Arizona State Hospital without a “Return to Work” (redacted).”
About 16 minutes later, the social worker then reentered the hospital and went to the (redacted), records show.
For the next two-and-a-half hours, nothing is documented in the hospital’s investigation until the social worker enters the patient’s room.
Here’s a summary of the state hospital’s version of what happened in the room:
5:05 p.m.
The social worker enters the patient’s room. The staff member who’s supposed to be constantly watching the patient talks with the social worker and then leaves.
5:08 p.m.
The two “kiss” and “embrace” before getting emotional. They talk and hold hands. The patient kisses the social worker on the temple a couple of times and pats her upper back.
6:07 p.m.
The social worker kisses the patient on the right cheek, gets up and walks around. The patient “patted/touched” the social worker on the “rump” as she walks by.
6:08 p.m.
The social worker “lay down on the bed and covered herself with a blanket.” The patient remained (redacted) next to the bed.
6:16 p.m.
Another staff member walks into the room and sees the social worker in the patient’s bed. The staff member asks if everything is alright, and the social worker said “everything was fine.” The staff member leaves and doesn’t say anything to anyone.
6:28 p.m.
“While laying in the bed (the social worker) removed her bra, while keeping her shirt on and not exposing herself. Other than removing her bra, both the (social worker and patient remained clothed during the incident.”
6:47 p.m.
The staff member, who initially was supposed to be on constant watch, returns and finds the social worker in the patient’s bed. That staff member advises other staff. More staff members enter the room. The social worker tells them “she was alright in the patient’s bed and she was married to the patient.”
The employee was then escorted from the room and police were called, records show. But no timeframe is given.
Sources dispute the hospital’s version of events, saying more happened in that room than officials documented.
INFORMATION ‘HIDDEN’ FROM OVERSIGHT BOARD
The Arizona State Hospital Human Rights Committee is a patient advocacy board, which has the legal authority to review reports of all incidents at the hospital.
“What really bothered me about the whole incident is that I heard about it from patients,” said Sharon Ashcroft, committee chair. “We didn’t get the incident report. There were gaps.”
Members said they get a batch of records every month, but this one was missing.
“So I asked, did we get that incident? And no, we’re missing that week,” Ashcroft said.
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Members said they asked repeatedly asked officials, including state Hospital CEO Donna Noriega, for the records. But it took more than 14 months for officials to finally turn over the one-page incident report.
They didn’t obtain a copy of the internal investigation until receiving a copy from an ABC15 reporter.
“We have little hope that they are going to cooperate with us on any level. It makes me wonder what else we haven’t received, and what else we don’t know about,” Ashcroft said.
Fellow member Jim Gillcoatt agreed.
“We’ve been stonewalled the entire time, and it’s very frustrating,” Gillcoatt said.
INSIDERS, PATIENT ADVOCATES RAISE QUESTIONS ABOUT HOSPITAL’S RESPONSE
Members of the Human Rights Committee said the hospital’s internal investigation lacks documentation and doesn’t detail what happened for long periods of time.
They said the most troubling is the amount of time between when the severity of the situation is finally recognized and police are called.
Staff recognize the problem at 6:47 p.m. Police are not called until 8:04 p.m. -- a gap of one hour and 17 minutes.
“I can tell you what happened,” said committee member Jim Gillcoatt, who worked at the state hospital several years ago. “They got a hold of the administrator on call. The administrator on call got a hold of the attorney. They’re trying to cover their tracks. That’s what happened,” he said.
Phoenix Police call logs show the incident is only reported as a trespassing.
In the log notes, it says “security has her pinned on the ground.” The hospital’s internal investigation does not include any of this information.
Phoenix police said they have no additional documentation of the incident. Nothing appears to have been reported to officers about what happened in the patient’s room.
Former county attorney Rick Romley said that’s a huge concern.
“That’s outrageous,” he said. “It’s truly outrageous. An extraordinarily vulnerable person potentially being sexually assaulted in the worst of ways, and they don’t even report it.
“It raises issues of, at a minimum, incompetence at the Arizona State Hospital to potential criminal misconduct,” Romley said.
As a former state hospital employee, Gillcoatt also raised questions about a patient census / checklist attached to the internal investigation.
The checklist shows that every patient was supervised and a wellness check conducted every 15 minutes.
From this incident, Gillcoatt said that obviously didn’t happen.
OTHER INCIDENTS / MORE QUESTIONS
ABC15 discovered six months before the incident, police responded to the social worker’s neighborhood on two separate days.
The social worker was having “mental breakdowns.”
In one, she removed her clothes and was “yelling she was going to be raped like the patient was,” records show.
Based on these police calls and the social worker’s comment that she was married to the patient, insiders said there are questions about whether this was an isolated incident.
A state health department spokesperson said they completed the investigation but found no other allegations regarding the social worker. However, no documentation was provided.
“The Department is looking to determine if there are additional documents that may satisfy this request. This will be an important part of the investigation. It will be comprehensive and conducted by an outside agency.”
The spokesperson was referring to an investigation announced Thursday in advance of ABC15’s investigation into uninvestigated sex crimes at the Arizona State Hospital.
The investigation will focus on patient safety, officials said.
The station uncovered several alleged sex crimes that were either not documented or disclosed under a court order and public records request.
Officials have not yet said which outside agency will be conducting the investigation.
The social worker is licensed in New York. But ABC15 has also learned no action has been taken against the social worker’s ability to practice.
State officials sent an email to the New York board of social work about the incident. However, it appears neither side took any further action.
“ADHS has no record of any contact to or from the NY Board after the initial email,” a health department spokesperson said.
The social worker is now employed at another facility.
Contact ABC15 Investigator Dave Biscobing at dbiscobing@abc15.com
