A Shattered Sanctuary: The TCV Homestead Incident and the Urgent Need for Safety in Residential Mental Health

    If you’ve read some of my other posts, you know that I have worked in both voluntary and involuntary residential settings. At both, the doors were locked, but for different reasons. One was locked to keep people in, the other locked to keep people out. Both are supposed to be places of healing and recovery where vulnerable individuals can feel safe while they get the support they need. But what happens when that sanctuary is shattered? 

 

    In 2016, a horrific incident at the Turtle Creek Valley (TCV) residential facility in Homestead, Pennsylvania, showed the devastating consequences of compromised safety in a space dedicated to mental wellness. It also tells the story of a company that responded appropriately to the incident and made their building one of the safest in the city of Pittsburgh.

    On a fall afternoon, a former patient, entered the TCV facility armed with knives and what appeared to be a handgun (later found to be a BB gun). Reportedly, the former patient also poured gasoline in the elevator but thankfully did not ignite it. In the ensuing chaos, five people were stabbed, some clients and some staff. A brutal act of violence that left a lasting scar on the victims, the staff, and the very community it was meant to serve. The perpetrator was eventually subdued by police and later sentenced to a lengthy prison term. The incident still casts a long shadow over the issue of safety in residential mental health care.

    The TCV Homestead tragedy reminds us that commitment to safety must be the bedrock of any mental health treatment environment. It's a commitment that extends beyond locked doors and security cameras; it's about fostering a pervasive "culture of safety" that permeates every aspect of a facility's operations.

Beyond the Headlines: The Aftermath of the Incident

    I remember seeing the news reports about this incident the day after it happened, sitting in the office of another mental health facility. There were two of us at work that day: myself and a man who had been in the field for 15 years. The face of the former patient responsible for the incident flashed on the screen, and my coworker turned to me. He said, "I know that person. I've worked with them before. This doesn't surprise me at all, they're one of the most violent person I've ever worked with."

     Years later, I was sitting in a new office. TCV Homestead's office. The floor I was now working on was the same floor where the incident had occurred. The building seemed so secure. I found myself wondering how anyone could have made it in who was not allowed in, especially with knives and a gun. Nearly every inch of the building was covered by cameras. There were doors that could only be opened with a key card or a specific key. The keys were always on the staff's person. Every door was locked when the room was not in use. When unknown people came to the door, staff members went out to speak with them, locking the door behind them. No one who did not work or live on that floor was permitted to be there. If visitors came, they would have to meet in the meeting room directly off of the unit. No one who was not permitted to be on the property would be immediately escorted away by the police (who were conveniently next door). I didn't understand. How could such a brutal attack have happened in such a safe space?

    One day, I met with my supervisor and asked her about the incident. She told me that, at the time, there were no cameras. None of the safety measures I saw had been here at the time of the incident. She encouraged me to look at the fire evacuation map that was hanging in every room. "You'll understand a lot better if you do," she said. "It hasn't been updated since then."

     When I did take a look at the fire evacuation map, I was stunned. The wall and main door to the unit had not existed at the time. The door that we closed behind us when we went to greet an unidentified person was not there. I looked closer. The staff office was in a completely different room back then. It was located in the meeting room. The one at the top of the elevator that visitors met with clients in. The entire floor was open to anyone coming up the elevator. The front part of the building had been built in the 1940s-1950s and was a hospital at the time. It made perfect sense for the floor to be that way. Because it had worked that way for so long, nothing was ever changed.

    What about the first floor? How did this former patient get in? I had a sinking feeling in my stomach. I already knew.

     Minutes later, I was looking at the evacuation map on the first floor. My suspicions were correct. The front door, the one that worked by key card, was not pictured. It wasn't there, I thought. Nothing was stopping him from going right up there.

Working at TCV Homestead

    I can confidently say that I have never worked in a place that had a feeling like that. It was like the hurt and fear had crawled into the cracks of that floor. Deep scars had been left from the incident. Not physical scars - the bullet holes were patched and the carpet was changed. In some ways, it was like it never happened. Except for the presence of the cameras. The emergency notification system they added, Dr. Quick, with boxes present in every room. The complete overhaul of policy that made everything so much safer. The new walls and doors added. The key cards and key rings, the expectation that all doors be locked when the room was not in use. New de-escalation tactics that were trained so often that you could practically do them in your sleep. 

     I was not present for any of these changes while they were happening. Four years later, everything looked normal. But every person who either worked on that floor was told about the incident. Reminded about how important safety is, and how quickly things can go wrong. It was typically a quiet floor, with calm individuals who wanted to get better.

     It was a fun job, but I eventually needed to move on to other things to get more experience. I will never forget the lessons I learned about safety there.