Western State Hospital has long struggled with an entanglement of challenges: staffing shortages, aging buildings ill-adapted for 21st-century psychiatric care and a lack of beds elsewhere in Washington for patients ready to be discharged.

Now, the coronavirus pandemic is adding a new and unprecedented layer of difficulty at Washington’s largest psychiatric hospital, an 850-bed facility in Lakewood.

As of Tuesday, 28 staff members and six patients have tested positive for COVID-19, the disease caused by the novel coronavirus, according to the state Department of Social and Health Services (DSHS), which oversees the hospital. Twenty-four staff members have recovered; one patient has died.

Western State staff, increasingly frustrated by what they see as a potential coronavirus outbreak, are calling on DSHS to take the crisis more seriously. They want more protective medical gear, better screenings for symptoms of the virus and better communication when workers have been potentially exposed to COVID-19.

And earlier this month, several advocacy groups wrote to DSHS urging the agency to reduce the number of patients at both psychiatric hospitals to cut the risk of a COVID-19 outbreak. The letter gave four suggestions on how to do that.

The hospital has recently taken some steps, including two requested by unions: the creation of a dedicated COVID-19 ward and letting staffers wear their own protective masks. Both measures are designed to slow or stop a wider outbreak.

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In an interview, DSHS Secretary Cheryl Strange said the hospital is in contact with the union, and her agency is trying to get more personal protective equipment like gloves, gowns and masks, which are desperately needed across the state.

“Most of our focus is on trying to communicate with staff, advocate for PPE, get some testing and really try to communicate well with labor,” Strange said.

Western State is hoping to transfer 60 civil patients to other health care facilities, in an effort to reduce crowding in the hospital that is virtually always near capacity, Kelly Von Holtz, a DSHS spokeswoman said. As of Thursday, seven patients had been discharged.

“WSH has multiple measures in place to prevent the spread of COVID-19, including the active screening process, the restriction of visitors, staff signage, and education to both staff and patients on proper precautions,” Von Holtz said.

But the hospital’s yearslong struggles — which in 2018 cost the facility its certification and $53 million in annual federal funding — continue to cause concern as it confronts a crisis not seen in anyone’s lifetime.

“They have historically had a lot of problems, and this I think has just destabilized them in a way that I think this is alarming,” said Kim Mosolf, director of the treatment facilities program at Disability Rights Washington, one of the organizations that wrote the letter.

The hospital’s patients include those sent from the criminal court system to determine if they are competent to stand trial, and those who have been deemed not guilty by reason of insanity. Other beds are for patients who have been involuntarily committed through the civil courts because of psychiatric illnesses.

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Even without the pandemic, the 2,700 staff and contract workers there face difficult working conditions, with hard-to-handle patients, some of whom are housed in out-of-date buildings. Staffers in 2019 reported more than 463 assault-related injuries.

Dr. Dinah Miller, an assistant professor of psychiatry and behavioral medicine at Johns Hopkins University, wrote that the virus creates “a new challenge” for psychiatric hospitals. Unlike regular hospitals, staff and patients don’t typically wear protective gear in psychiatric units, Miller wrote, and the treatment of psychiatric illness requires things like group therapy, which bring more social interaction.

“It’s not hard to imagine the distress of anyone who has a patient spit on them as we’re all trying to remember not to shake hands,” Miller wrote in Clinical Psychiatry News.

Staff at the hospital, and their union, the Washington Federation of State Employees, have complained of lax communication from management about potential exposure to the virus, a lack of personal protective equipment and insufficient screenings for symptoms of the virus.

Western State announced its first positive test, in a patient, on Thursday, March, 19. Rosalyn Lee, a nurse at the hospital, said she treated the same patient the weekend before the positive test. She was off for three days after treating the patient, before she learned about the positive test.

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Lee texted her manager when she heard about it, who, she said, told her she could still come in to work.

“You would think they would be doing some contact tracing, but I was never contacted,” Lee said. She eventually tested negative for the virus.

Lee, who supervises the nurses on her ward, said she doesn’t have a good answer for them when she’s asked what they should do if they don’t feel safe working there. She simply refers them to her shift manager.

“I’ve had to sort of think about do I toe the company line and do what management says, or do I go with my gut and my nursing training,” she said. “What I do tell them is, ‘use your brain and take care of yourself, don’t trust that anyone else is going to take care of you.'”

A few weeks ago, Loren Kennedy, a mental health technician at the hospital, saw on the news a patient had tested positive. When he came back to work, “I was going, hey, we need to get masks, can we get masks?”

“The only way they would allow us to get masks was if we were dealing with a patient,” Kennedy said.

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When his partner, who also works at the hospital, started showing symptoms, she was sent home, Kennedy said. Eventually they both tested positive.

Staff had been told they could not wear their own masks, as it could frighten patients or create a false sense of safety from the virus. The hospital changed that policy March 31. Around that time, it also created an isolation ward, for patients who have tested positive or are awaiting test results. It is trying to limit movement between wards, to minimize the potential spread of the virus, a DSHS spokeswoman said.

Staff are now being screened when they report to work, but through an “attestation model,” in which they simply sign a form saying they do not have symptoms.

Meanwhile, a registered nurse at the hospital said Western State by late March wasn’t following its own guidelines restricting staffers from moving between different wards.

One day, the hospital assigned that nurse, who didn’t want to be named for fear of retaliation, to one ward before then directing the nurse to instead work on a second ward. The nurse protested, asking to work on the ward originally assigned, and was eventually sent home rather than working a shift.

Mike Yestramski, a psychiatric social worker at the hospital and president of WFSE, said hospital management needs to be more responsive to workers’ concerns.

“Until they start taking this seriously and understand what they are up against,” said Yestramski, “we are going to be fighting a losing battle.”