Matt Solan is overwhelmed.
Solan has been a patient at the Arizona State Hospital since April 2020, found guilty of aggravated assault with a deadly weapon. Because he was found to be “guilty but insane,” a special designation in Arizona law, Solan was sent to ASH, as it’s often known, instead of prison.
The idea is to rehabilitate, rather than punish, so that patients can someday rejoin society and lead fulfilling, safe, productive lives.
Instead, Solan and other patients say ASH is making them worse.
According to state hospital medical records Solan provided to KJZZ, the 35-year-old has been diagnosed with anti-social and narcissistic personality disorders. As a child, he was also diagnosed with autism.
It’s the lack of accommodations for his autism, Solan says, that is causing him distress.
“Well, if I could sum it up in one word, I would use the word torture,” he told KJZZ in a phone call last fall.
It took weeks to arrange the timing of the call with Solan’s lawyer — and on the phone, the background sound makes it easy to hear what he means when he talks about sensory overload.
“Every single room and the hallway and corridor from the day room to the treatment rooms, to the bedrooms, to the bathrooms, they just amplify noise. And the echo here is horrible … So no matter where I go in here, I can't escape the sensory overstimulation that all this noise and motion and commotion causes.”
Between patients, staff, walkie-talkies and TVs, the place is so loud, he says, that Solan has willed himself nocturnal — sleeping through the day and waking up at night when it’s quiet and there’s less stimulation.
“On the average day when my sleep schedule's not interrupted for one reason or another, I would sleep all day. I would wake up around dinner. And then I would get on the computer and I would stay on the computer and do paperwork and research. I spend probably 12, 13 hours a day studying, reading and practicing drafting documents and writing computer code to the extent that I can ... And I just do that all night until the sun comes up.
“And then, usually before breakfast is served, I'll go to my room, I'll take out my little game player, watch a cartoon until I can't keep my eyes open and go to sleep and sleep the rest of the day.”
In a written statement, the Arizona Department of Health Services declined to answer any specific questions, but did say that accommodations are provided to patients with autism.
“To ensure quality care and promote patient recovery, ASH has options for patients who need support in sensory regulation. Quiet rooms, weighted blankets, and noise-cancelling headphones are incorporated into care plans for patients when clinically indicated. We work with a vendor that specializes in equipment that cannot be tampered with or used for self-harm, so staff are able to implement these accommodations for patients quickly and safely.”
Solan’s medical records show that ASH nurse practitioner Kindra Ochoa ordered noise-cancelling headphones in August 2024.
In legal documents Solan provided to KJZZ, the patient says that Dr. Maitreyi Prabhu at ASH ordered soothing epsom baths many times — but later revoked the order.
"I basically am out of all of my coping tools.”Matt Solan, AHS patient
“Appellant’s medical provider, Dr. Prabhu, wrote multiple orders over the years for staff to dissolve Epson salts in Appellant’s bath water, and staff had routinely provided sufficient Epson salts for Appellant to take 2-4 baths a week. The last Epson [sic] salt order was set to expire in 2025; however, Respondent’s administrators ordered the groundskeepers to turn off the water to the bath tubs, which they did, except for one unit. When Appellant protested, Dr. Prabhu claimed that other patients had a doctor’s orders, and that is why the water was not turned off for them. When Appellant maintained that he, too, had a doctor’s order, Dr. Prabhu exclaimed that “baths are not medically necessary,” stormed off, and discontinued the order. Appellant asserts the discontinuance was made in retaliation for having voiced his grievance.”
Solan says both baths and headphones have been withheld.
“One of the shower rooms has a bathtub in it, to help with grounding and cooling off. And over the last, I don't know, four months, the hospital imposed a bunch of sweeping changes that haven't made much sense, but they effectively came in and said, the bathtubs are permanently closed, nobody can use them, and shut off the water to them,” Solan says.
“They seized my headphones when they raided the whole hospital after revamping their contraband policy … I basically am out of all of my coping tools.”
Solan was also unsuccessful recently in suing the hospital to allow him access to his therapy dog.
Last fall, Solan was charged with aggravated assault against an ASH employee. His attorney, Holly Gieszl, says this is not the first time one of her clients with autism has been punished for acting out after being denied accommodations.
“There is inadequate training of staff — so they taunt, incite patients, and do not de-escalate behaviors that are the result of a mental or cognitive disorder,” she says.
Because diagnosing mental health conditions is more of an art than a science, it’s hard to know how many people across the U.S. with serious mental illness also have autism. The study of “dual diagnoses” is relatively new.
KJZZ spoke with two other patients in the forensic unit at ASH who report similar experiences to Solan’s. The sister of a former patient says her brother, whose diagnoses include autism, emerged from ASH much sicker than when he went in. Attorneys representing patients at ASH say substandard treatment is widespread, and advocates for the autism community say the place is shrouded in secrecy, making it impossible to know what is really going on.
Because diagnosing mental health conditions is more of an art than a science, it’s hard to know how many people across the U.S. with serious mental illness also have autism. The study of “dual diagnoses” is relatively new.
If you’ve lived in metropolitan Phoenix for any amount of time, chances are pretty good that you’ve driven past the Arizona State Hospital — and never knew it.
Located on 90 acres at the northeast corner of 24th and Van Buren streets, the hospital complex is wrapped in chain link fencing lined with razor wire and trimmed in hot pink bougainvillea.
Last year, the bushes were cut way back and now it’s possible to see orange-clad inmates from the Department of Corrections exercising on the dead winter grass. There are mysterious, gorgeous old buildings that may or may not be occupied today. A newer administrative building with a big “no trespassing” sign hundreds of yards in front of the entrance keeps the place shrouded in secrecy, and employees leaving at shift change look away from observers standing on the trash-covered public sidewalk.
If you have heard of the state hospital, it’s probably in regard to Winnie Ruth Judd, the infamous “trunk murderess” who was a patient at ASH between 1933 and 1971 and escaped seven times.
On the southwest corner of the ASH grounds, a small structure is being built to someday provide transitional housing for a few dozen patients.
On the far northeast end, there’s a long, unkempt lot packed with graves of long-ago ASH patients, including children.
The hospital opened on this spot in 1887. The 1912 annual report includes a long list of diagnoses that landed people at what was then called the “State Asylum for the Insane,” including alcoholism, sexual perversion and melancholia as well as the “feeble minded,” now referred to as intellectually disabled.
By the 1940s, the place was packed with hundreds of patients, including many World War II veterans, and the population topped 2,000. In 1970, the Arizona State Legislature voted to discharge anyone who was not deemed a danger to themselves or others, and patients streamed onto Van Buren Street without much more than a few dollars and the clothes on their backs.
If you have heard of the state hospital, it’s probably in regard to Winnie Ruth Judd, the infamous “trunk murderess” who was a patient at ASH between 1933 and 1971 and escaped seven times.
A class-action lawsuit, Arnold v. Sarn, called on the state to fully fund services for the mentally ill, and in an attempt to further limit institutionalization, capped the number of civil unit beds available to Maricopa County at 55.
Today, ASH houses fewer than 400 patients, including Matt Solan. About half are in the forensic unit, for residents with severe mental illness who have been found guilty of a crime and ordered by a judge to get treatment. The rest are civil commitments, those who are considered a danger to the community, but haven’t been charged with any crime.
Like the inner workings of the Arizona State Hospital, specifics of just how our brains work can be hard to come by.
When you think of autism, you likely recall that diagnosis rates among children began to climb in the mid-1990s and continue to soar. But unless you have a family member who has autism or are otherwise close to an autistic person, you probably don’t think or know much about what happens to an individual with autism when they reach adulthood.
Some kids eventually do appear to “outgrow” their symptoms, depending on their level of need (remember, autism is a spectrum) and the kind of therapy they receive in younger years. Applied Behavior Analysis, or ABA, is a very intense program that trains children to behave more “normally,” and in recent years has fallen out of favor with many people in the autism community.
This in part explains the sensitivity many have toward the idea of “therapy” for adults with autism.
And then there’s the reality of how adults with autism are received by society.
Cynthia Macluskie is director of advocacy for the Autism Society of Greater Phoenix.
“I think that when you're small and cute and young and easily directed, that's where some people like to stay,” she says. “And the older that you get and the more needs you might have, the more opinions you might have, makes it maybe more difficult to work with and treat.”
But the number of adults with autism is going up as kids on the spectrum age and adult diagnoses increase. It’s tough to know how many of those people have a dual diagnosis — but the problem is significant enough that in 2022, the federal government created the Link Center, housed under the Administration for Community Living and designed to help people with dual diagnoses of intellectual and developmental disabilities and mental health conditions.
Jennifer Johnson, a member of the Administration for Community Living executive team, says the work is just beginning.
“There's a lot of challenges in terms of not only, you know, the challenges in terms of us not having national data on this population to know exactly how many there are and sort of their co-occurring conditions and their general health status. But also, it's hampered by the fact that it can be very hard to get a differential diagnosis of somebody … is it their intellectual disability? Is it a mental health disability? Sort of truly understanding, you know, the differences between the two.”
The national data isn’t there — and the local numbers at ASH have not been made available. But it is known that serious mental illness like schizophrenia or bipolar disorder occurs more often in people with autism than it does in the general population.
When you think of autism, you likely recall that diagnosis rates among children began to climb in the mid-1990s and continue to soar. But unless you have a family member who has autism or are otherwise close to an autistic person, you probably don’t think or know much about what happens to an individual with autism when they reach adulthood.
Researchers are just beginning to ask, “Why?”
“We understand the behaviors associated with autism, but we don't understand the biology that's contributing to them,” says Blair Braden, a researcher at Arizona State University who specializes in autism and aging. “We really don't know that much from a research perspective. I would say the things that we do know, broadly speaking, is that most cases of autism are caused by a variety of genetic differences that are really hard to pinpoint in any one individual. A lot of genes contribute to autism risk, and then things that people experience in their environment that we don't have a good handle on either.”
While researchers grapple with the hows and whys, many people impacted by autism and serious mental illness are just trying to make it through the day.
On a midweek afternoon in early November, Sommer Walter and her son Ryan welcomed visitors. The house was already decorated for Christmas, per Ryan’s request. The tall, dark-haired young man is curious about the visitors’ radio equipment.
Ethyn, Walter’s older son, keeps a distance. Both young men, 18 and 20, have autism – but it presents differently in each. Ryan is physically affectionate and has a lot to say. Ethyn is a little more complicated.
“He's my lover,” Walter says. “He's my, he's the non-verbal one, Type 1 diabetes. A lot of the health stuff, you know.”
Every couple hours, including during the night, Walter pricks Ethyn’s finger to check his blood sugar.
Both Ryan and Ethyn tower over their mom. Toddler toys like stackable rings and a Little Tikes plastic keyboard crowd the kitchen table. On the fridge, there’s a hand drawn valentine, an arithmetic worksheet and phone numbers for doctors.
Ryan retreats to his bedroom, obviously bored. Ethyn wanders the living room, iPad in hand, watching “Sesame Street.” After a bit, he trades the tablet for a big pink ball and stands patiently by the back door till Walter opens it. Outside on the concrete patio, Ethyn bounces the ball repeatedly. His mom says he can do it for hours.
On this warm autumn afternoon, the house is calm. That’s not always the case. A few weeks later, Walter posts a bathroom mirror selfie on Instagram. She’s looking straight ahead, wearing giant safety goggles over her long brown hair.
The caption: “When your kiddo has autism and likes to poke your eyes out when you’re trying to assist him in the bathroom … this becomes your new safety attire!!”
Walter added a laughing emoji to the post, but in the photo her eyes are exhausted. The threat to her safety is real. But she worries more about her sons than herself. She knows the worst case scenario.
Autism was not new to Walter when her sons were diagnosed as little boys. She has both a half-brother and half-sister who are autistic. Their upbringing was traumatic, Walter says, and she’d fallen out of touch with her brother, Darren William Beach Jr., for more than a decade when she saw a familiar face one day on the television news.
Newscasters were reporting an arson attack on a Phoenix LGBTQ youth center called One-n-Ten. Walter watched the security footage of a tall, wide set man in a blue hoodie walking around the inside of the building, pouring gasoline.
Walter visited her brother in jail as soon as she could. Since she’d last seen him, Beach had been diagnosed with schizoaffective disorder and was living on the street.
He was found guilty but insane in the arson case and sent to the state hospital in 2021.
As she’d later testify before the state Legislature, Beach got worse at ASH — not better — in part because he was not given accommodations for his autism.
“He just kept getting increasingly aggressive,” she says. “You take someone with autism and you throw them into this sensory overloading, stimulating unit where patients are constantly attacking each other, or staff is being attacked by the patients. And so that is what really made the shift in Darren’s stay at ASH. That's when they started increasing all the meds, changing meds, flipping the meds … I mean it was, it's abusive. It's just abusive, what they did to Darren,” she said. “He got worse.”
Not only did ASH not provide accommodations, hospital medical staff removed Beach’s autism diagnosis, Walter says.
“They took the time to have him evaluated by somebody who is not someone that is credentialed or versed in autism, especially for those with adults that is not clinically trained to do that. They undiagnosed him with autism at ASH so that they're like, ‘he doesn't have autism.’ And I'm like, ‘but he does. He’s had this longstanding diagnosis since he was like, 4, you don't magically not have autism anymore.’”
Almost two years into his stay at ASH, Beach was found guilty of aggravated assault against an ASH employee and sent to jail. The nine medications he was on at the time did not follow him, and Walter says he began having a physical reaction that culminated in a psychotic break.
Beach declined KJZZ’s request to be interviewed. He has not spoken to media since the arson incident.
Walter is disappointed in the system — and herself.
“I was very naive in thinking like, ‘Oh, this is gonna be a piece of cake. I'm gonna be able to get Darren all kinds of help. This is gonna be great. He's gonna get outta jail, and life is gonna be awesome for him.’ … I don't even think there's a word to describe what has happened with Darren and his situation. … Just, epic failure. Just an epic disgusting, awful failure.”
“As you age it just gets harder and harder. Like, yeah, I'm 41, but I've now started thinking, OK, what happens to my kids?”Sommer Walter, who has 2 autistic sons
That naivité is gone, particularly when it comes to her sons.
“We stopped having in-home providers come in because I didn't want them to get hurt. So I'm Ethyn's habilitation provider now, um, because I just, I just feel awful. I know some families are like, ‘oh, well that's their job and if they just get beat up, you know,’ I'm like, ‘no, no. That's how you lose providers,’” she says.
Walter continues: “My husband and I have a deal. We're like, no, we're just gonna let Ethyn beat the [bleep] out of us because we're not calling the police.”
It takes too long for help to arrive, Walter says, and when it does, the officers are often not trained to deal with people with autism and mental illness.
Walter pauses as Ethyn, done with the ball, hands her a container of Reese’s peanut butter cups. OK, she says, but first his blood glucose needs to be checked.
“Can we sit?” she asks, taking his hand and pointing to his fingers. “Which one? Which finger? Wanna do that one? You better do a little bit better than that. Nice hands, kid. Which one? This one? Of course. It's always the middle finger, right?”
She laughs, not unkindly.
“Let's check it. Sorry. Sorry. I'm sorry buddy. I'm sorry. I'm sorry. There we go. Good number my friend. Good number. OK. You want one or two? No, we can't have five. OK.”
Ethyn blows a kiss to his peanut butter cup before he eats it.
Unlike her brother, Walter’s sons have received therapies and other services for their autism since they were very young. Walter wonders what would have happened if Beach had received that kind of care. But even with it, she worries about her sons — particularly Ethyn.
“With someone like Ethyn, it's very isolating,” she says, “… ‘cause you don't know when that behavior is gonna pop off with him. You don't. And he's gone after me in the store and I get it. It looks frightening, you know? Um, and the police have been called, you know, and the police show up in the Target and I'm just like, ‘No, no.’ Like, they come in and I'm like, 'Back the hell up,’ and they're just like, ‘What?’ I'm like, ‘Back up, back up. I got it. He's autistic, he's nonverbal, he's aggressive. I got it.’”
And she does. Until the day that maybe she doesn’t. Walter worries all the time about what will happen when she’s not around anymore.
“As you age it just gets harder and harder. Like, yeah, I'm 41, but I've now started thinking, OK, what happens to my kids?” she says.
“Even caring for Darren, I'm like, ‘God, I pray I outlive him.’ ‘Cause I know what's to come for them. Like Ethyn, he'd probably die soon after, you know, I passed because they couldn't do, it's very hard to place someone like Ethyn who's aggressive and medical, you know? … And then Ryan, I couldn't imagine the heartbreaking, you know, positions that they would, that he might be placed in. You know?”
Today, Darren William Beach Jr. is doing better, his sister says. He’s out of jail and living at Valleywise, Maricopa County’s psychiatric hospital, as he waits for a suitable community housing placement.
Valleywise has been a game changer, Sommer Walter says. And that is because of Dr. Carol Olson.
Olson is the medical director for the hospital’s psychiatric division. She sees patients who have been ordered by the courts to receive treatment and are waiting for available beds at the state hospital or elsewhere. Sometimes a patient waits for months or even years. Because Valleywise is a hospital setting and not equipped for long term living like ASH, Olson says that can be a negative — imagine being stuck in a hospital room for months on end.
Unlike ASH officials and medical personnel, Olson agreed right away to an interview as long as it wasn’t about specific patients.
A tour was a different matter. Although promised, it was rushed. Microphones had to be turned off as reporters were escorted through heavy metal doors and past a few empty rooms in the adolescent unit.
There’s a whiteboard on one wall, with a daily schedule. Every minute is accounted for. A callbox-style phone hangs on a wall in front of the nurse’s station, encased in plexiglass. Each living quarter holds a small cot, and one empty room at the end of the hall is reserved for “time outs.”
The tour ends in Olson’s office, where she competes with piles of paperwork and books to find a spot to sit and talk. She, too, does not have formal data. But Olson is seeing a “significant” percentage of patients with autism and serious mental illness. She and her staff do their best, she says, to provide accommodations. The financial cost can be high.
“In almost all cases where the person has significant autism, we have a one-to-one staff member with them at all times. … So that's one of the reasons why a lot of hospitals don't want to take people with autism or other types of developmental disorders because it requires extra staff for that person.”
There are easier, more affordable ways to help patients with autism, Olson says.
“Obviously we can try to do things like weighted blankets or doing other types of kind of more sensory modalities for people.”
Apparently that is not so obvious to others. Two other patients in Matt Solan’s unit at the state hospital spoke with KJZZ and asked that their names not be used because they fear for their safety.
“I've been here at the hospital seven years and haven't got treatment for my autism, PTSD, anything, any of that,” one patient says.
“When I was a kid as well, when I got too anxious, my mom would say, ‘go take a warm bath,’ and … it would calm me down immediately… that was a huge coping skill for me and they took that away.”
Another patient says his autism has become “a common struggle” at ASH.
“I used to calm myself down by taking a bath, but now they've shut off the bathtubs,” he says. “There's so much wrong with this place … you know, if prison is hell, this is purgatory.”
“ASH is bound by both the Americans with Disabilities Act and the Arizonans with Disabilities Act to make sure that they provide the needed reasonable modifications for individuals with disabilities. If it's something that's needed for a disability, there needs to be an individualized assessment to determine how to accommodate that disability.”Asim Dietrich, Disability Rights Arizona attorney
Matt Solan echoes the sentiments. “I end up in the situation I'm at now with still no treatment and no faith that when I get out, the exact same thing isn't gonna happen the first week I'm out there,” he says.
Holly Gieszl, Solan’s attorney, says treatment plans are a joke — and no one at the hospital will take accountability for what is or is not happening.
“Everybody stands in a circle and points left.”
Patients are isolated for having an emotional outburst, Gieszl says — and that means therapy is withheld. To her, that makes no sense.
“You don't go to treatment when you're restricted to the unit. You don't get to go to your groups. So if you throw your orange juice against the wall because you have intermittent explosive disorder, you just lost a month of treatment,” she says.
“Please, please ask why, why is the Arizona State Hospital permitted to discipline people who are the most severely mentally ill there?”
The path to reforming the system isn’t clear, because pretty much everyone involved agrees that the law clearly requires ASH to provide accommodations for patients with autism.
Asim Dietrich is an attorney with Disability Rights Arizona, a nonprofit agency funded by the federal government that represents people with disabilities.
“ASH is bound by both the Americans with Disabilities Act and the Arizonans with Disabilities Act to make sure that they provide the needed reasonable modifications for individuals with disabilities. If it's something that's needed for a disability, there needs to be an individualized assessment to determine how to accommodate that disability.”
Other Arizona laws specifically mandate that appropriate treatment be provided for patients at the Arizona State Hospital. But that doesn’t mean they are being enforced.
State lawmaker Catherine Miranda, a Democrat, is concerned.
“To have autism and the psychotic disorder like schizophrenia together, I mean, they have to meet these patients where they're at. And that's not happening,” she says.
In a statement, ASH officials say that when warranted, accommodations are given to patients with autism. But without more detail on either end, it’s hard to know what’s really going on inside the hospital.
It could simply be that there’s not enough funding available.
According to a clinical improvement plan, ASH CEO Michael Sheldon released in 2023, the hospital doesn’t have enough state funding to hire staff who are specifically trained to work with patients with autism. The same report concluded that ASH had more than 80 full-time staff vacancies, and needs a total of 117 positions filled to meet its current obligations.
“To have autism and the psychotic disorder like schizophrenia together, I mean, they have to meet these patients where they're at. And that's not happening,”Democratic state lawmaker Catherine Miranda
This is not a new challenge. In 2021, Sheldon’s predecessor, Aaron Bowen, told lawmakers that ASH couldn’t accommodate patients with autism.
“We do not have the ability to treat autistic spectrum disorders or developmental disabilities. … Without the appropriately trained niche staff who specialize in this type of treatment, it's very challenging for ASH to accept these types of patients into the state hospital and effectively treat them.”
But additional funding won’t change the fact that there’s little transparency or accountability when it comes to the Arizona State Hospital.
One reason so many serious matters remain unresolved, advocates say, is because independent oversight committees have no power. IOCs, as they are known, are mandated by state law and operated by the Department of Administration as a way of monitoring the state hospital as well as the state’s Division of Developmental Disabilities. Members of the state hospital’s IOC review redacted internal reports, ask questions and listen to patient concerns. But beyond reporting their findings, IOC members can do nothing.
Autism advocate Cynthia Macluskie has many years of experience sitting on an IOC.
“We have the power to ask questions and we ask and we ask and we push and we push. But we don't have the power to make them do anything,” she says. “They can hear it, they can give advice. It doesn't mean the system has to follow it … We don't have any real power.”
The most recent annual report for the ASH IOC, dated October 2024, details a range of concerns — including a lack of immediate medical attention at night and on weekends; that the Phoenix Fire Department was not responding to calls as there was confusion over whether the ASH forensic unit is a prison or a hospital; and allegations by patients of retribution when they complain to the IOC and elsewhere.
The report also noted that “loud dayrooms and bright lights have caused discomfort, especially for patients with autism spectrum disorder.”
“We have the power to ask questions and we ask and we ask and we push and we push. But we don't have the power to make them do anything,” she says. “They can hear it, they can give advice. It doesn't mean the system has to follow it … We don't have any real power.”Autism advocate Cynthia Macluskie
IOC members also reported concerns that staff were acting inappropriately.
“We substantiated claims that two employees were very aggressive and acted in a manner that escalated situations,” the report reads. “Four committee members reviewed the videotapes of the incident. The employee was put on administrative leave while investigating the incident but later returned to work on the unit. The employee involved in the incident was part of the treatment staff [and was seated next to the patient in a staffing]. The two staff had been reported to the IOC previously as intimidating to the patient. During a treatment meeting, while communicating new disciplinary plans, the seating placement resulted in another altercation during the meeting. We felt this could have been avoided by different seating placements or different employees present at the staffing. As reported by other members of the IOC who work in psychiatric facilities, when there is a known ongoing conflict between patients and staff, the staff is often removed from that patient’s treatment team.”
The IOC’s annual report also notes concern from patients over the fact that the state agency that operates the Arizona State Hospital is also charged with monitoring the hospital’s performance and holding it accountable. It’s not just patients who are unhappy with that. Advocates came close to getting that law changed in 2024 — but ultimately failed.
“If DHS imposes financial penalties against Arizona State Hospital, [they’re] basically imposing financial penalties against their own department,” attorney Asim Dietrich says. “So that's unlikely to occur. And then the other thing is to either terminate or suspend a license. And again, that's unlikely to occur because ASH is the only facility for most of the patients who reside there. You know, it's their last, their last stop where everything else has been tried.”
Will Humble has also championed the effort to keep the state hospital from, in effect, monitoring itself. He headed the Arizona Department of Health Services from 2009 to 2015 and is now executive director of the Arizona Public Health Association.
“A lot of the decisions that state agencies make are based … are based on self-preservation and administrative ease, rather than what's best for the state,” Humble says.
The state Department of Health Services is responsible for overseeing all kinds of medical facilities in the state, including hospitals. The department posts results from the last three years of inspections, including penalties.
Over this period, state inspectors noted that ASH failed to secure bathrooms, leading the possibility that a patient could use a faucet as a “tie off point” in a suicide attempt and violating patient rights. It was also noted that the hospital failed to ensure a patient’s bedroom was safe by “having areas in which a patient could cut themselves.” Inspectors also noted that staffing numbers were continually under the required levels; and that staff were not properly trained in policies regarding seclusion and restraint of patients.
And another citation noted that 5 out of 5 seclusion or restraint rooms “contained mirrors made of plexiglass, that had sharp edges, mounted on the interior wall of the rooms. … The top of the mirrors, which were within reach of patients, in all five rooms, had sharp edges that were not beveled. When touching the edges of the mirror in the first restraint/seclusion room observed, one surveyor was cut on the hand by the mirror.”
It was also observed that the “fire alarm pull station” was obscured and that monthly sprinkler systems inspections had not taken place. Frayed power cords were being used.
In a statement, ASH officials say that when warranted, accommodations are given to patients with autism.
Over this three-year period, ASH received two enforcement actions — one for the forensic unit, the other for civil. Each one resulted in a fine of $500.
On a practical level, Humble says he understands why accommodations like those Matt Solan is requesting aren’t always made available.
“What can happen is administrators, medical directors and staff start to become more and more restrictive over time. Because if you give someone a privilege, noise canceling headphones as an example, and something bad happens with that, then you're gonna say, why in the world was this person given noise canceling headphones and they took out the battery and ate the battery? And you'll get in trouble for having given them the headphones.
“On the other hand, if you, if someone needs noise canceling headphones and it's gonna help with their therapeutic treatment, and you deny that person the headphones, because you're risk averse, you don't get in trouble.”
That is not the right direction, Humble says. He holds Gov. Katie Hobbs responsible for ASH’s shortcomings.
“It's really key for the governor, the executive, to hold those agencies accountable, to say, `Wait a minute, you're not here to make your job easy. You are here to meet the needs of the patients in Arizona.’”
Special thanks to KPNX-TV and ABC 15 for permission to use reporting from newscasts and to KTAR for permission to excerpt a 1969 documentary about Winnie Ruth Judd.
EDITOR'S NOTE: The people observed in orange jumpsuits at the Arizona State Hospital were Department of Corrections inmates, not Arizona State Hospital patients
Resources
Link Center – Federal center that focuses on research and information about the dual diagnosis of serious mental illness and intellectual and developmental disabilities
Association for the Chronically Mentally Ill – Arizona-based organization devoted to advocacy around services, support and housing for people with serious mental illness.
Arizona Mad Moms – Arizona-based organization devoted to advocacy around services, support and housing for people with serious mental illness.
Autism Society of Greater Phoenix – Local organization devoted to advocacy related to autism.
Arizona Independent Oversight Committees – Committees created by state law, devoted to monitoring activity at the Arizona State Hospital as well as state services for people with intellectual and developmental disabilities and other vulnerable populations. Membership application is open to the public.
Arizona Department of Health Services Inspection Reports – AZCARECHECKS allows you to search inspection reports and enforcement actions regarding everything from childcare facilities to marijuana dispensaries – including long term care facilities for vulnerable populations and medical facilities including the Arizona State Hospital.
If you have a story you want to share, questions, or just want to talk, please reach out to Amy Silverman and Athena Ankrah. You can email us at [email protected] and [email protected]. You can also call or text us at 480-205-1687.
