PHILADELPHIA — When Alex Zachariah went to work at Norristown State Hospital one afternoon in May 2021, he noticed one of the patients struggling.
“He was limping and grimacing in pain,” Zachariah said. Growing concerned, he asked a few of the other patients what was wrong with the frail young man, whom Zachariah described as barely verbal. Eventually, he said, they told him the story. “They said this guy was standing in the medication line, and he had in his hand a Styrofoam cup of Ensure. And his hand was trembling violently, and he spilled some Ensure onto the shirt of one of the guards — and this guard picked him up and slammed him to the floor,” Zachariah said. “That’s what they told me.”
Zachariah said he knew patients at the institution were not always reliable witnesses. But he was concerned enough to email hospital administrators, urging them to check the surveillance camera.
What followed, he alleged, was his introduction to what he came to view as a culture of abuse and cover-ups in the forensic unit of Norristown State Hospital, a secure facility that treats incarcerated people with mental illness. Over the next year and a half, Zachariah would become focused on exposing those alleged abuses — a fixation that he said drew professional repercussions and threats of violence, and an investigation that could cost him his job.
Norristown’s forensic unit is one of two in Pennsylvania that evaluates and treats people who have been deemed incompetent to stand trial. Like a prison, its secure buildings are encircled in razor wire. Its guards, called Forensic Security Employees (FSEs), are members of the state correctional officers’ union.
Among civil rights and defense lawyers who represent defendants with mental illness, Norristown retains a sterling reputation. Witold Walczak, legal director of American Civil Liberties Union of Pennsylvania, said that when he last toured the facility seven or eight years ago he was struck by how superior it was to the “bedlam” of the jails. He found the phrase “therapeutic milieu” at last made sense to him, he said.
Yet, three people who have been incarcerated there said that, on the contrary, they felt far safer in jail or state prison. “I thought I was going to die there,” said Elvis Rojas, in an interview at a Philadelphia jail, which he described as a haven by comparison.
Seven current and former employees who spoke with The Philadelphia Inquirer described a permissive culture on the Norristown’s forensic unit, where staff were able to bring in contraband such as cellphones and alcohol, and to sleep or watch pornography on the job.
They alleged that some FSEs sought to incite or escalate conflicts, so they could then call for patients to be given shots of sedative.
They also alleged that some FSEs committed brutal assaults in video surveillance blind spots — and then attributed the injuries they caused to patients falling out of bed. Some said FSEs commented that, since they were in a mental hospital, patients’ complaints would not be believed.
“Those are the ones I know of,” Zachariah said of the six assaults patients reported to him over the past year and a half. He said he saw one man suddenly missing teeth and another with “gruesome” burns. “One guy lifted up his shirt and showed me the bruises. One side of his body was beaten black and blue. Falling out of bed doesn’t cause this.”
By the state’s own data — the most recent available runs through April 2022 — Norristown is a relatively violent place compared with the state’s five other state-run psychiatric hospitals, most of which treat people who are committed through a civil process. The rate of injuries in the forensic unit there due to patient-on-patient assaults was about 75% higher than the average for all of the state-run psychiatric hospitals from May 2021 through April 2022, according to state Department of Human Services (DHS) statistics. Injuries caused by patient-on-staff assaults were 43% more common than elsewhere in the state system.
In addition, DHS documented 20 allegations of abuse in Norristown’s forensic unit. That accounted for close to half of all abuse allegations made across the state hospital system, though the unit accounted for just 14% of all days of care.
Staff on the unit also gave “stat” — or emergency — injections of psychiatric medication 1,641 times during that period, according to the reports. They administered 25 such shots per 1,000 days of care, more than double the rate at the other state-run forensic unit at Torrance State Hospital. The use of “stat” psych meds at Norristown in April 2022 was by far the highest of any state psychiatric hospital, and 80% higher than the state’s average.
State hospitals are required to notify the nonprofit Disability Rights Pennsylvania of alleged abuse. Nash Boone, managing attorney in charge of investigations and monitoring at the nonprofit, also conducts unannounced visits at least once a year. Boone said he hears complaints from patients across the state hospital system about physical abuse and misuse of chemical restraints
“An allegation like that is not necessarily uncommon,” he said. “The trick is trying to figure out if it’s substantiated or not.”
The Department of Human Services, which administers the state psychiatric hospitals, declined requests for a tour of the hospital and for an interview with hospital administrators. DHS declined to comment on individual incidents and did not respond to questions about how many staff had been disciplined in connection with alleged misconduct.
In an email, DHS press secretary Brandon Cwalina said that all allegations are documented and, when necessary, investigated. “Hospital administrators may take additional safety precautions during an investigation of incidents involving staff such as reassigning to work on a different unit or to work off all units, or suspension pending the outcome of the investigation,” he said in the statement. “Establishing and following a rigorous incident and abuse investigation protocol is required in order to maintain licensure of the hospital.”
He also said that the heavy usage of stat medications simply reflects the patient population at Norristown, which includes many new admissions “who present with higher acuity, and as a result, often require stat medications until they reach a more therapeutic medication and treatment stabilization.”
After the spilled Ensure incident, Zachariah heard that an FSE was suspended but was later allowed to return to work.
Weeks after he reported the incident to higher-ups, he said, the phone rang in his office.
The male voice on the other end, according to Zachariah, gave a succinct warning: “Snitches get stitches.”
‘Stay in your lane’
Zachariah, now 66, went to Norristown after 15 years working in Pennsylvania state prisons. He was a counselor there and, before that, a corrections officer — a job whose true nature had been lost in translation at first when he immigrated to the United States with his family.
“I did not know that a corrections officer was a guard,” he said. Back in India, he had worked in the employee training center of a large bank, he said. He had hoped to put his behavioral science background to work in Pennsylvania’s civil service. “I saw the position of ‘corrections officer,’ and I thought it was something to do with counseling people.”
Court records show Zachariah ran into conflict in the prison with colleagues he accused of near-constant racially motivated harassment. He filed complaints and then an employment discrimination lawsuit, which settled in 2014. He said the promotion to counselor was part of that agreement.
Eventually, in 2019, he applied for a post at Norristown. The state hospital, he believed, would be more closely aligned with his ideal of rehabilitation.
But Pennsylvania’s state mental hospitals have a long and troubled history.
Starting in 1912, Pennsylvanians deemed criminally insane were sent to Farview State Hospital — a foreboding brick institution in the northeastern Pennsylvania town of Waymart. The hospital made national headlines in 1976 after an Inquirer investigation revealed that guards had brutalized and even killed patients, and left others naked in locked cells for years. Other inmates, arrested on minor charges, were detained for decades without ever receiving a psychiatric evaluation, let alone treatment.
By 1978, the state announced plans to phase out Farview — the building now houses a state prison — and replace it with two new forensic units, including the one at Norristown. Officials promised top-notch psychiatric treatment, “with every possible security consideration.”
Since Norristown opened, observers have generally taken a positive view.
In the most recent publicly available performance audit of Norristown, in 2013, the Pennsylvania auditor general found that operations were largely adequate, including sufficient protocols to investigate abuse allegations. Its western Pennsylvania counterpart, Torrance State Hospital, has drawn greater scrutiny, including over staffing shortages that, Spotlight PA recently reported, continue to raise safety concerns.
In 2015, the ACLU sued the state on behalf of defendants with mental illness, some of whom were waiting a year or more to be admitted for treatment.
“We’re still in a monitoring and compliance period,” Walczak said of that case, which only addresses wait times, not hospital conditions. He said an expert retained by the ACLU was “really impressed” with the staff at Norristown.
This spring, the state announced a $242 million investment in Norristown State Hospital, the first step toward replacing its midcentury forensic buildings while expanding its capacity from 275 patients to 450.
But Boone, of Disability Rights Pennsylvania, said some reports he had received concerned him.
“I think that Norristown may have an issue with their forensic unit in terms of patient safety,” he said.
“Norristown is a very unique hospital in the Pennsylvania state hospital system, and I think they see a lot more problems than the other hospitals,” he added. That’s in part due to the challenging caseload and the large forensic unit, he said. “And then the overall conditions at Norristown seem to be a little more problematic than at the other state hospitals in terms of general upkeep, complaints from the patients. … Some of those allegations are troubling, to say the least.”
Zachariah’s job at Norristown was to provide therapeutic and recreational services. That is, running bingo games, playing music and organizing chess games for the patients in one of two forensic buildings.
In summer 2021, he helped organize a barbecue for the patients. While he was cleaning up, he said, a supervisor pulled him aside. He needed to find a way to get along with the guards, the supervisor said — and telling on them would not help.
By now, however, Zachariah believed that the assault he’d reported was part of a pattern.
That summer, he said, he encountered a Lehigh County man who had been beaten so badly his jaw was broken and had to be wired in place.
The man is Raymond Delgado III, who has schizophrenia and was facing aggravated-assault charges when he was sent to Norristown in 2021. He’s now in state prison, having pleaded “guilty, but mentally ill.” In an interview, Delgado said he was assaulted twice at the hospital.
On one occasion, he said, a patient he’d barely interacted with walked up and, without a word, punched him in the face once, breaking his jaw. He said that he never knew for sure what motivated it, but he later saw the man eating french fries — outside food only staff could procure. In his view, that aligned with rumors that some staff used food to reward patients who carried out attacks upon request.
Another time, Delgado said he saw an FSE roughly shoving another man against a wall. Delgado punched the staffer — and, he said, then faced retaliation. After that, he said, a nurse injected him with a sedative, and five FSEs pushed him into a patient’s room. Then, he said, they “started hitting me on my head, kicking me in the ribs, and stomping on my back.” He said that when he fought back, he was injected with a second shot of sedative and beaten more.
“The abuse should never be going on in a hospital,” he said. “You’re supposed to be setting a good example. Giving people strength to overcome their issues. Instead, you’re jumping and beating on people.”
Just days after that, Zachariah said, he encountered the patient whose torso was covered in bruises.
That man, Nikolay Lukyanchikov, is now serving a state prison term for shooting his dog and then burning its body.
Lukyanchikov told The Inquirer that he was “severely beaten by two guards” in August 2021, leaving him bruised and “in excruciating pain for weeks.” He said that he subsequently developed PTSD and that, a year later, he still has trouble sleeping.
Zachariah said that, when he asked around, he was told by co-workers that investigations were underway.
That summer, though, he was increasingly worried about the future of his own job.
A few weeks after the barbecue, he was called into a meeting with two supervisors, he said.
“Stay in your lane,” Zachariah said the supervisors told him. He said that he took the message as: “Life will be difficult for you if you keep reporting things.”
‘Quiet! You never seen nothing’
For a few months, Zachariah said, his workdays were uneventful.
Then, in November, word of another violent incident began to circulate.
It involved a man in his 40s, who was severely scalded while at Norristown. The man was at the hospital because he’d been found incompetent to stand trial for arson and burglary in Montgomery County. According to the crime blotter of the local newspaper, The Reporter, he had wandered — completely naked — into an unlocked garage and set fire to “some loose pieces of paper using a lighter, producing smoke.”
The man, according to an internal email obtained by The Inquirer, was “sent to ER, then Temple Hospital burns (unit). (The doctor on duty) did not know how the burns occurred.” DHS statistics for that month indicate one patient from Norristown was hospitalized in connection with alleged abuse.
Zachariah said he was alarmed when he saw the man’s “gruesome burns.” So were several other staffers and patients who spoke with The Inquirer.
One patient, Craig Boston — then awaiting trial in Bucks County for stabbing an ex-girlfriend outside the Oxford Valley Mall — wrote in a letter to The Inquirer that he saw Norristown security staff beat the man in a bathroom before he was burned. He wrote that staffers were frustrated because the man was incontinent. He also alleged that he had heard staff talking about how they would “turn the shower all the way up hot on his a--.” Boston said he spoke up, but a staffer told him, “This is how he will learn.”
Boone, of Disability Rights Pennsylvania, said he was told the incident was under investigation. Whether or not abuse was involved, he said, the incident is cause for concern. “If you have a facility where it’s in such a state that someone is able to burn themselves, to me that suggests something is wrong.”
Some Norristown staff, reached by phone, said they observed only caring professionalism in their colleagues. They said they did not believe that any physical or verbal abuse had occurred.
But the seven current and former employees who spoke with The Inquirer said they saw a climate where such violence was routine and misconduct was largely met with impunity. They cited patterns of nepotism in which relatives were able to get one another hired, then protect each other from discipline.
Two said security staff would intentionally provoke patients, then demand that nurses sedate them. Three also said it was common for staff to work double-shifts for overtime, and then sleep on the job. Four said they were threatened with retaliation if they reported misconduct.
“It’s a lot of abuse, believe me. … Yelling, pushing, everything happens,” said Karen Mojica-Santana, who resigned from an FSE job in 2019. She said patients who did not speak English, in particular Latino patients, were frequent targets. “The patients told me all the time: ‘He hit me. He beat me in my room,’” she said.
She came to fear that reporting abuse could cause her to lose her job, she said. She alleged that colleagues and union officials alike told her to keep silent and to lie to investigators. “They said: ‘Quiet. You never seen nothing.’”
The president of the Pennsylvania State Correctional Officers Association, which represents 282 FSEs at Norristown, said in a statement that false accusations happen, but no staff had faced retaliation for reporting misconduct. Of Mojica-Santana’s account, PSCOA president John Eckenrode added: “That is not something we train our union stewards to do or say. We do everything we can to properly serve our members, who work one of the most dangerous jobs in the commonwealth.”
Aleeia Burton, who started in June 2021 as a psychiatric nursing assistant there — “I thought I lucked out by getting a state job,” she said, “because I’m still 27″ — said her concerns prompted her to leave after just nine months.
“I felt like eventually what I went to school for is going to be on the line just from working there,” she said.
She said she witnessed staff being “verbally abusive to the patients” and heard about investigations into physical assaults, including the patient who was scalded with hot water. She said a few guards were temporarily placed on “no-patient-contact” status but retained their jobs. “You can only get in trouble for what they can see (on camera).”
Other current and former employees spoke on condition of anonymity — because they still had relatives working at Norristown or because, even after leaving, they said they feared retaliation including physical violence.
One former psychiatric aide said it was common for security staff on the forensic unit to retaliate against and “fight” particularly difficult or aggressive patients. He believed it was “understandable” and said he did not hear of serious injuries.
“There were places that don’t have cameras, like bathrooms and certain corners. … That one patient who was spitting on people — they would finally get him into the bathroom. They would walk out and they would always say, ‘He fell,’” the former aide said.
A current Norristown security staffer gave a similar account: “There is no way someone can just wake up with a black eye. … And there is no way the patient could have gotten second-degree burns unless the staff did something to him.”
The worker said that the code of silence was well-known and that a nurse even threatened to slash the staffer’s tires if the staffer spoke out.
“The culture at Norristown is, don’t snitch,” the employee said.
A former security employee said he is still haunted by what he saw at Norristown — and by what he failed to stop from happening. Almost daily, he would encounter staff behavior that discomforted him. “The amount of uncomfortable can’t really be named. Sickening sometimes. And you can never talk about it because of HIPAA.” (The Health Insurance Portability and Accountability Act protects the privacy of patient health information but does provide an exception for the reporting of abuse.)
He said co-workers made clear that reporting abuse could cost his job.
“I definitely did partake in some activities of patient abuse. I wouldn’t be beating any patients, but me being in the room and not saying anything,” he said. “I gotta pay the bills, and telling doesn’t pay them. You would have to really care [to tell].”
Without any special skills or certifications — many FSE trainees come to Norristown from jobs in food service, home health care, or warehouse work — he was making more than he’d ever earned in his life: $30 an hour plus overtime.
He said he worked on a challenging unit, with patients who were unpredictable and, at times, violent. He admired how some security staff were skilled at deescalation, never losing their tempers.
Others, he said, took revenge.
He said such incidents happened in the patient’s room, where there are no cameras. “They would avoid the face, I guess,” he said. “They know the patient’s credibility is not believable.”
He said he saw one guard put liquid soap in a patient’s mouth.
One incident involved a patient who defecated on the floor. He said an FSE woke up from a nap and was so enraged by the mess that he proceeded to “slam him on the head into the s---.” The employee said he then brought the patient to the bathroom to wash up. “I leave and come back to see them holding the patient under the water in the bathtub.”
One former employee resigned after less than a year, after a patient claimed he was “jumped” by security staff.
“I decided it was no longer a safe place for me to stay,” the former staffer said.
The ex-employee described FSEs using “excessive force” to restrain patients — including once sitting on a man’s chest. He complained of rib pain but refused an X-ray to determine whether he had broken ribs, according to the ex-staffer.
The person also said that FSEs frequently demanded that nurses dose patients with powerful sedatives.
“If (a patient) was getting on their nerves, they would incite them — then call a nurse to put them out for 12 hours,” the ex-employee said. “They used a lot of unnecessary chemical restraints there, which is against the law, and (the security staff were the ones telling nurses) to give it.”
The former staffer was chilled after learning about a 1999 incident in which a disgruntled employee — hired despite a criminal record and history of drug use — returned to the hospital after being fired, took hostages, and killed a nursing administrator. The worker came to believe the cultural problems had deep and long-standing roots.
“The (patients) may have psychiatric illnesses or behavioral issues, but the guards are not supposed to have behavioral issues. The guards are hired to take care of them, not to abuse them. They’re supposed to be able to control themselves.”
‘They’re not going to believe you. … You’re crazy’
In February of this year, another Norristown patient asked Zachariah for help.
Justin Yost, a Lancaster County man, alleged four or five FSEs had dragged him out of a day room into a patient bedroom, held him down, and, as he put it in an interview with The Inquirer, “beat the s--- out of me.” He said they stomped on him and then smothered him so that he could not breathe, while he “prayed it would stop.” Then, he said, a nurse injected him with a sedative.
Yost wanted help getting the paperwork needed to file a grievance, the first line of recourse for an incarcerated person. He told Zachariah no one would give him the forms, or even tell him the names of the FSEs who allegedly attacked him.
Zachariah gave Yost the form he needed. Yost, who has since been sentenced to state prison for disseminating child pornography, would later file a lawsuit in federal court. In it, he claimed that staff at the time offered other patients bribes of food not to cooperate with an investigation.
Yost’s lawyer, Seth Carson, said even when he went to meet with Yost, security staff were “physically intimidating,” interrupting their conversation and preventing them from speaking privately.
“I told my client: ‘I’m going to fix it. I’ll figure out how we can have a real conversation and I’ll be back.’ And the guards were telling me: ‘You’re never going to fix it. You’ll never meet with them by themselves. We’ll always be here.’ They were right, by the way.”
Meanwhile, Zachariah was encountering other patients who made similar allegations.
One was Rojas, 47, who complained of recurring physical and sexual abuse.
In an interview, Rojas said some staff did work to keep him and other patients safe. He also acknowledged that at times he had lost his temper, yelling or throwing water at a staffer.
He alleged that the retaliation was fierce, including beatings and unnecessary injections with the sedative Thorazine. In a grievance form dated Feb. 2, 2022, Rojas wrote that about a dozen staffers had “jumped” him and one punched him in the head. “I was struggling not to be put in my room, ‘cause I’ve seen staff beating on patients numerous times. So they got me in and beat me up bad enough where my right eye feels like it was hit by a brick.”
He also alleged that an FSE had repeatedly fondled him. “He was like: ‘They’re not going to believe you. You’re here. You’re crazy. They won’t believe your word over mine.’ … It was a very uncomfortable feeling. I felt so vulnerable.”
Rojas, a disabled former truck driver, spoke at the Philadelphia jail, where he was awaiting trial for gun possession. A longtime Kensington resident, he lives on the same narrow block as his parents, chaplains who run a mobile ministry they call the Spiritual Pharmacy. He said the gun arrest followed months of trying to clean up the block, and of being threatened by drug dealers angry that he and his parents had turned over video to assist police in a shooting investigation. He said he found the gun while cleaning a vacant lot, kept it for protection, and then drew it on a driver he mistook for one of his harassers.
Navigating Philadelphia’s Curran-Fromhold Correctional Facility (CFCF) in his wheelchair, Rojas keeps his most valued possessions close by in a pocket behind his seat.
“What keeps me sane is this right here,” he said, reaching into the pocket and producing a well-worn Bible. “This is my strength. If it hadn’t been for this, I would not have made it through Norristown State Hospital.” He also kept his journal from his nine months at Norristown, which he considers the worst time of his life. A kindly staffer had given him the notebook, to record his good days and bad days. “I never had a good day there at all,” he said.
His father, Jose Rojas, said his son had also reported the abuse to him contemporaneously, in phone calls from Norristown. He said he was relieved once his son was back in jail — even though he was stabbed there by another prisoner.
“I think he’s a lot safer at CFCF, at the prison,” he said. “It’s sad to say, because it should be the other way around.”
Recently, Rojas pleaded guilty and was released from jail without any of his prescriptions or medications.
‘Now, I’m the target of an investigation’
This summer, according to Zachariah, his situation had reached a boiling point.
“A patient told me some of the guards were threatening him, asking him, ‘Do you want to be taken to the room?’” Zachariah said. “That is a code word. For me, room is a place where they don’t have cameras.”
Another told him a guard had asked if he enjoyed his sandwich — because the guard had spit in it.
Each time, he provided a grievance form. Then, he submitted it on the patient’s behalf.
A few weeks after that, he claims, a security staffer confronted him, saying: “‘I hear you’ve been reporting stuff about people. Any more reports and you’re going to have trouble with me personally. The consequences will not be good for you.’ So I said, ‘Can you elaborate?’ [He said], ‘No, I’ve got nothing more to say to you.’”
Zachariah interpreted that as a threat that qualified as workplace violence — and reported that, too.
He claimed that two other people were witnesses, including a nurse, Susan Vogelman. But, reached by phone, Vogelman said she could not hear the conversation over what she described as an extremely noisy air-conditioning unit. She said she resented Zachariah’s mentioning her name.
“He is a troubled employee who doesn’t do his job properly and doesn’t get along with anyone — and I am not a witness to any workplace violence that he is alleging,” she said.
Zachariah said he was told the investigation determined he had not been a victim of workplace violence.
So, he’s made more reports: to a state senator, a state representative, state police and the Pennsylvania attorney general. A special agent for the Attorney General’s Office has contacted some witnesses, including Vogelman. A spokesperson for the Attorney General’s Office declined to comment.
In August, Zachariah filed yet another grievance — against the outcome of the grievance process. He ended it with a quote in Latin and English: “Quis custodiet ipsos custodes? … Who will guard the guards themselves?”
He said that in September he was finally called into a meeting.
“Now they say I’m the target of an investigation,” Zachariah said afterward.
He was told he’d been accused of inappropriate conduct: intimidating Vogelman, “by hollering at her” and causing a criminal investigator to visit her home.
After months of pleading for intervention, Zachariah is now getting the mirror image of what he wanted all along: investigation and swift action. He said he’s been banned from the forensic unit while he awaits a formal disciplinary hearing.
“They said the investigator will be contacting me and will take a statement.”
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