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Concerns over the operations of St. Elizabeths Hospital, the District’s public psychiatric facility for people with serious mental illness, continue to mount two years after the end of federal oversight of the institution.

A recent report offered objectively damning evidence that the city-run hospital, whose daily census averages 300 patients, is a dangerous place. Between December 2015 and February 2016, there were 632 assaults, 384 injuries, and 524 incidents of physical and mechanical restraint, according to an investigation by the watchdog organization Disability Rights DC.

Now, City Paper has learned that a severe water main rupture in August left the hospital and its patients without water for nearly a week. The hospital was forced to rely on bottled water for drinking and flushing toilets, and on hand sanitizer and moist towelettes for hygiene purposes. The incident, which posed health risks for both patients and staff at St. Elizabeths, was compounded by the hospital’s lack of effective communication both internally and externally.

At 6 p.m. on Aug. 6, the General Services Administration (GSA) received notification of a rupture along the pipe that supplies water from the federally owned West Campus of St. Elizabeths to the District-owned East Campus, where the hospital is located. By 10 p.m., GSA had turned off the water supply to the East Campus to begin assessing the damage. The rupture ran the entire length of the 60-foot pipe, according to GSA. In the following days, the East Campus switched to a District-owned water supply, but safety tests delayed when the hospital could begin using the water. By Aug. 11—five days later—the water was cleared to use for laundry and bathing, but it wasn’t deemed safe for consumption until the next day.

“The hospital immediately implemented its tested emergency water plans to maintain clinical care and minimize impact on operations,” Phyllis Jones, legislative and public affairs director for the Department of Behavioral Health, which oversees the hospital, writes in an email. This included relying on bottled water for “drinking, cooking, flushing toilets, and other essential functions.”

The hospital also depended on “a combination of alternative hygiene practices and common hygiene products during the water interruption.” Patients and staff used hand sanitizer in place of washing their hands with soap and water. In lieu of functioning showers, patients had to bathe themselves using moist towelettes throughout the week.

Since common hygiene products are less effective at killing germs than soap and water, the week-long water outage posed an increased risk of spreading infection. According to the Centers for Disease Control, hand sanitizers do not kill certain germs, such as those that cause norovirus. While the concern would be significantly greater if the hospital were an acute care facility, according to Linda Greene, president-elect of the Association for Professionals in Infection Control and Epidemiology, the risk of spreading infections is always heightened when a hospital does not have running water.

The circumstances that caused the water outage were largely out of the hospital’s control. The pipe that ruptured was approximately 80- to 100-years-old, according to the GSA, and its walls had been worn thin by constant use. When it came to switching the water supply, the hospital was at the mercy of negotiations between federal and District agencies. And the possibility of transferring patients would have caused more harm than good in many cases.

The hospital, however, failed to effectively communicate the situation both internally and externally, which Greene says is crucial during incidents of this nature.

“The primary issue with any [hospital] disruption is good communication,” she says. That means maintaining “conversations with staff, patients, and their families” and offering the opportunity “for people to ask questions.”

In the days after the rupture, patients contacted Disability Rights DC to complain that they were not informed about what was going on at the hospital. 

“Throughout the entire week, individuals at St. Elizabeths complained they did not get information about the status of the repair or the progress being made to resolve the situation,” says Jen Lav, managing attorney at Disability Rights DC. “Some reported that they were using the water to shower and wash their hands, while others were told it was not safe for any purpose. Some complained that for several days toilets were not working. We had serious concerns that the information given to residents was inconsistent at best.”

Some bathrooms and water fountains, according to patients who contacted Lav, were cordoned off while others were not. The communication breakdown posed a risk to patients because using or consuming water that is potentially unsafe can cause the spread of illness or infections. Jones concedes St. Elizabeths made no effort to notify patients’ families of the situation. 

St. Elizabeths also failed to alert the court system until two days into the water outage. On Aug. 8, a St. Elizabeths administrator sent an email to court personnel warning that the hospital would not accept incoming patients for pre-trial evaluation or post-conviction commitment. The hospital did not begin accepting patients again until Aug. 12. According to a Superior Court official who spoke on the condition of anonymity, St. Elizabeths gave the courts no prior warning about the water outage or the possibility that it might need to temporarily stop accepting incoming patients. 

According to Jones, 14 people who were charged with crimes and referred by the courts to St. Elizabeths were instead held in the D.C. Jail during the water outage. 

The hospital provided no public announcements about the incident, which helps explain why there was no media coverage. According to Linda Greene, many hospitals “will have town-hall style meetings to make the public aware of what is going on” when a disruption of this nature occurs. 

According to the hospital’s Emergency Operations Plan, unusual emergency incidents should be treated as “critical opportunities” to assess the effectiveness of the plan and evaluate improvement areas. “For all real emergency incidents reaching level 2 or above,” which includes hospital-wide water outages, “the Emergency Planner should prepare an After Action Report,” it reads. According to Jones, such a report is in the draft stage and “any final agency action as a result of the incident will be made public.” 

The hospital’s failure to report and review incidents goes back over a decade and was described in a scathing 2006 report from the Department of Justice. One section of the report specifically cited the lack of an effective infection control program and mandated that the hospital “actively collect data with regard to infections” and “identify necessary corrective action.”

CORRECTION: An earlier version of this story misquoted Linda Greene. We regret the error.