Chester G. Quimby was the administrator of a large public hospital that included several levels of psychiatric and non-psychiatric units. He was a somewhat humorless man whose sole interest in running a hospital was keeping the balance sheet positive and avoiding the clinical staff where possible, as well as patients or their broods at all costs. For these reasons, Chester had a rear entrance to his office suite built and a private elevator to his secured parking.
To keep costs low, the facility had a mix of salaried hospital employees and contract workers. The contract workers cost more in direct salary, but had no significant other costs like a pension, paid time off, or health insurance, and served as no threat of any sort to the salaried employees. Chester and his captive HR department made sure that salaried employees knew quite well that they could be replaced by a contract worker at the stroke of a pen. Chester had also established contacts in Eastern Europe and Latin America to provide contract workers whose rates were very competitive, and he was looking into expanding into medical tourism facilities in Latin America where he could send elective patients and get greater profit with fewer headaches from unions. He had used these same pipelines to lower his janitorial and maintenance costs. All in all, things were peachy for the bottom line.
Evelyn worked as a psychiatric nurse manager on 5 West, which was a locked adult acute psychiatric ward. It was hard work, as all nursing jobs tend to be, but it carried an extra emotional toll and additional risks. The patients were often decompensating by the time they were in the psychiatric ward, at peak levels of anxiety, depression, or psychosis. The admission process itself was often a cause of the patient’s heightened conditions, and it fell to the nursing staff to bring some sort of order and calm to these patients while they were settling in. Part of those duties involved keeping surprising events in the ward to a minimum and avoiding situations that might tend to dysregulate the patients and push them beyond their capacity to cope. Every new admission, every visitor, and every change in staff or routine threatened to be a trigger for one patient or another, thereby setting off a decompensation cascade. To add to their burden, recent cost-reduction policies had trimmed nursing and support staff; at the same time, the number of beds increased.
Due to the cost-cutting measures by the administration, there were some complications to the seclusion rooms. One of those was that some of the seclusion units shared a toilet with a standard room used by non-secluded patients. To avoid secluded and non-secluded patients mixing or coming into contact, the hospital policy was that the door between the toilet and seclusion room would normally remain locked, only to be unlocked by a nurse when the door to the unsecluded room had been secured. This was all very well on paper, but in practice it meant that every time one of the secluded patients needed to use their toilet, a nurse had to stop what they were doing and manually lock the unsecluded side, unlock the secluded side, and then manually lock and unlock after the secluded patient was done. Since psychiatric medications sometimes caused loose bowels, the door dance with several toilets could become time-consuming and tedious for the nurses. Despite very delicately worded memos to management about this burdensome affair, especially if the room became foul and needed janitorial services, there was no response from administration.
A threat from the nurses’ union finally got the attention of the administration, and Chester was pressured to “go sort it out.” This proved more difficult than he had envisioned, and on their home ground, the nurses and their union representatives insisted on using the meetings to itemize demands and grievances, of which there were many. The meeting location shifted from one ward to another over the next few days, and but for signs of incremental progress and the beady eyes of the union representatives, Chester would have given up and just forced through the cuts and policies he desired. On the third day, it was the turn of the psychiatric nurses, and the discussion moved to safety and toilets. Chester was growing tired of the whole affair, and had almost enough progress to just call it done and bulldoze any remaining issues. Almost, but not quite enough…
Brian was a patient in Evelyn’s ward and had a history of issues with controlling his emotions. He was not seen as a likely assault risk, but had regularly been confined to a seclusion room for unpredictable behavior. On Thursday, he had chased another patient and hurled a bedpan when the staff had tried to intervene. The flying bedpan got Brian moved to unit 7A, which was a locked seclusion room. The seclusion had taken effect, and he was now less agitated. The staff had kept a wary eye on him and made sure everything remained quiet and predictable so nothing would startle him back into a state of agitation and paranoia.
Slight progress had been made for the psych nurses regarding shift rosters, ward cleaning services, and administrative burdens, but they had become stuck over the topic of understaffing. Chester argued that adding nurses was very costly, that all other options to reduce waste and improve efficiency would need to be exhausted before adding more staff. Evelyn thought that he simply didn’t understand the issue, while he believed she was overcomplicating it and making a fuss out of nothing. The issue eventually boiled down to toilet doors, and with a dismissive wave of his arm, he cut Evelyn short. The mood became tense, and when the nurses rose as one to walk out and discuss strike options, Chester realized he had overplayed his hand. He irritably agreed to walk the floor with them to see what they were so upset about.
On the ward, tempers were still frayed, and Chester stomped along with much harrumphing and eye-rolling. Evelyn showed him an example of a room with two patients that shared a toilet closet with a seclusion room. Still not seeing the issue, and growing frustrated, he strode through the next room and threw open the toilet door. The door slammed into the stop in the adjoining seclusion room with a bang.
Brian was doing a meditation exercise that his psychiatrist had taught him when the toilet door crashed open. He leapt to his feet in alarm and felt an immediate, overwhelming sense of panic. With adrenalin and stress hormones peaking, Brian glared toward the noise, ready to defend himself. He heard a noise behind him as a nurse tried to distract him by rapping on the armored window of the closed and locked door that was the primary entrance to the seclusion room. He was immediately suspicious, though, and spun back around toward the toilet door projecting into his room. Seeing the suited interloper in his toilet room, Brian launched himself across the floor while Chester was frantically trying to claw the door closed. Before Chester could duck, run, or get more than a despairing little shriek out, Brian dived and captured him in a rib-cracking tackle. Due to Brian’s enthusiastic forward motion, they fell over together, and the back of Chester’s head hit the toilet bowl with the kind of thud that a bowling ball makes when dropped on solid oak.
The orderlies and nurses sedated Brian, the ward slowly returned to a semblance of calm, and Chester was transported to the ER. Emergency surgery was performed to release pressure on his brain and control the bleed, but just before midnight, the last staccato breath left Chester, and he was pronounced dead without ever regaining full consciousness or understanding how his cost cutting caused his own death.
