JAMESTOWN, N.D. — A psychiatric patient in the North Dakota State Hospital with a criminal record of assault had announced his “dark thoughts” and “murderous compulsion” before he attacked a housekeeper, resulting in charges of attempted murder and assault.
Those comments and a series of escalating behaviors — including an escape the day before the March 2019 attack — were red flags that warned of the dangers posed by the patient, documented in a report by a psychologist who evaluated the patient that was obtained by The Forum.
The patient, Jason Benefiel, was experiencing delusions that staff members at the state hospital were trying to harm him and he had previously assaulted other employees at the hospital, according to a Jan. 25 report by clinical psychologist Deirdre D’Orazio.
D’Orazio characterized Benefiel’s behavior before the assault of housekeeper Christin Eastman on March 29, 2019, as “behaviorally aggressive and bizarre.”
Her description of Benefiel’s behavior and comments was drawn from interviews with hospital employees, some of them recorded, and was an addendum to an earlier evaluation of Benefiel submitted in July 2019.
“He told staff he feared he was losing his mind, that he was having ‘dark thoughts,’ ” which he described to one staff member as “loud thoughts that he couldn’t quiet telling him to hurt or murder someone and that he couldn’t breathe,” D’Orazio wrote in the Jan. 25 supplemental report.
Benefiel believed his safety depended upon escaping from the state hospital — something he managed to do briefly the day before he assaulted Eastman, who was working alone, cleaning restrooms at the time of the attack.
At times, Benefiel appeared aware of the threat that he posed, even asking staff to place him in seclusion, according to the report.
Despite Benefiel’s threatening comments, pleas for seclusion, and aggressive behavior, he was allowed free movement at the time of the attack, Eastman told The Forum. She was not warned of his violent past or of the comments he had made to other staff members, she said.
Unlike nursing aides, custodial staff were not equipped with radios so they could summon help, a security lapse that Eastman said was addressed after her attack, which left her unconscious, requiring hospitalization and surgery. She is unable to work and suffers from post-concussive syndrome and post-traumatic stress disorder.
During the 48 hours preceding the attack, Benefiel’s aggressive and violent behaviors escalated. He threatened to harm a female staff member and physically attacked a male staff member, D’Orazio wrote.
Nick Archuleta, president of North Dakota United, which represents public employees, said the psychologist’s report shows that a series of warnings and red flags could have prevented the assault against Eastman, if heeded.
“It seems to me they missed an awful lot of warning signs,” he said. “The administration should have intervened much earlier in this sad tale.” Eastman was doing her job, but administrators failed to do theirs by protecting staff from a patient known to present a safety risk.
“That shows a blatant disregard for the health and safety of public employees,” Archuleta said.
Rosalie Etherington, superintendent of the state hospital, declined to be interviewed about the report or to answer specific questions, though did issue a brief statement.
“The North Dakota State Hospital takes multiple precautions to keep staff safe,” she said in the statement. “Our safety measures meet or exceed hospital safety best practices, and the fact that violent incidents and injuries are below the national averages for hospitals demonstrate their effectiveness. In spite of this, serious incidents do occur.”
The callous disregard that state hospital administrators showed for the safety of their employees would result in legal liability if it were a private workplace, Archuleta said. Laws should be changed to allow public employees legal recourse beyond workers’ compensation when their employers’ negligence results in injury, he said.
Staff safety concerns at the state hospital, which last year sparked an online petition seeking the removal of Etherington and another top administrator, should be investigated by an independent authority, possibly the North Dakota Legislature, he said.
“There should be a very serious investigation into what caused it,” Archuleta said of the assault.
State hospital employees presented their safety concerns anonymously, but said they did not want to do so publicly because they feared retaliation. That underscores the need for stronger whistle-blower laws, so public employees can speak freely about their concerns so serious problems can be addressed, Archuleta said.
“It’s clear to me they did not take this guy seriously” as a safety risk, he said.
According to D’Orazio’s report, Benefiel’s request for seclusion was denied, staff members told her, because the state hospital was in the midst of an accreditation evaluation by The Joint Commission, including a site visit, and seclusion was not permitted.
Surveyors thought the state hospital was secluding patients unnecessarily, although patients were not locked in rooms, Etherington told The Forum last year.
The seclusion room, called intensive care, was closed on March 20, 2019 — nine days before Benefiel assaulted Eastman.
Staff members told D’Orazio, who practices in Atascadoro, Calif., that Benefiel usually walked barefoot, but was wearing shoes on the day of the attack, suggesting he possibly was planning to escape.
Despite his psychotic state, D’Orazio concluded that Benefiel’s behavior showed the capacity to plan and exhibit “goal-focused behavior” within 24 hours of the attack. “He showed the capacity to comprehend that the immediate consequences of his behavior would lead to removal from the current setting, which his symptoms of his severe mental disorder led him to believe was necessary,” she wrote.
Angela Simpson, a nurse who founded and directs Silent No More, a support and advocacy group to protect health care employees from workplace violence, said the assault against Eastman reflects an alarming lack of security at the North Dakota State Hospital.
“This facility has historically shown a spectacular lack of concern for staff safety,” she said. “Lack of adequate security, other staffing, training, cameras, ability to seclude patients, as reported to us in the past by other staff members, creates an already dangerous situation.”
Those problems were compounded by administrators’ “knee-jerk response” to the poor evaluation of the hospital’s frequent use of restraint, causing the hospital to close seclusion rooms before Eastman’s attack, Simpson said.
“They are used to protect patients and staff,” she said of seclusion rooms. “Closing these down completely is negligent and, yes, completely indifferent to the safety of staff.”
D’Orazio’s report shows a pattern of ignored warning signs, Simpson said, adding that it can be difficult, however, to know when someone with schizophrenia is “escalating in a way that will be dangerous or violent.”
Still, Simpson added, Benefiel’s escape the day before and evidence he was planning another attempt — wearing shoes, which he ordinarily didn’t do — would require “close monitoring” that apparently was not in place.
“There was no point in time when someone untrained in severe warning signs should have been alone with him, nor should he have been able to access that area in the first place,” she said.
“Bare” staffing levels at the hospital also created an environment in which the assault was more likely to happen, Simpson said.
“As reported to us in the past, they rarely have more than one or two security officers on at any given point in time, and they can’t be everywhere at once,” she said.
The report makes clear that even Benefiel recognized that he was a risk to others and asked for help, Simpson said. “But no precautions were taken, and this innocent woman, not trained in psychopathology, was left vulnerable and almost died,” she said. “I’m just livid.”
Earlier this year Benefiel was found not competent to stand trial because of his severe and chronic mental illness, including acute schizophrenia.
Benefiel has a criminal record that includes a previous assault against a law enforcement officer and a history of violent behavior, including writing letters threatening to kill or torture, D'Orazio wrote.
In 2010, in an example D’Orazio cited in her report, another evaluator wrote of Benefiel, “Given his long term pattern of behaviors and mental illness, risk of causing serious harm to staff remains a strong possibility that should be at the forefront of all future staff interactions.”
Now, whenever state hospital staff are in close contact with Benefiel, they work in pairs for safety, Eastman said she’s been told by former colleagues.
“It’s pretty messed up that it takes what happened to my wife to cause them to go to a buddy system,” Charles Eastman said.