Feds extend deadline for Brattleboro Retreat; issue new rules on subduing violent patients

Brattleboro Retreat Psychiatric Hospital. Creative Commons photo/Flickr user pag2525

Brattleboro Retreat Psychiatric Hospital. Creative Commons photo/Flickr user pag2525

Editor’s note: This story by Olga Peters was originally published in The Commons issue #220, on Wednesday, Sept. 11.

BRATTLEBORO — Two years after the Brattleboro Retreat opened its doors to patients displaced from the Vermont State Hospital, the 179-year-old psychiatric hospital continues to wrestle with patient rights and staff safety.

During an unannounced investigation on July 15 and 16, the Centers for Medicare and Medicaid Services determined that the Retreat, which specializes in mental health and addiction care, violated federal polices.

Again.

The Retreat has not met CMS conditions on at least four occasions this year.

In this case, the violation involves circumstances under which Retreat staff have called the Brattleboro police to assist with uncooperative patients. In response, the Retreat has outlined changes to its security policies in a letter to employees for in-patient units — namely, the hospital’s “Use of Police Response to Safety Emergencies” policy, which has been eliminated.

Some staff members described feeling caught in a pinball machine, bouncing between attempting to care for patients, complying with state and CMS policy, and protecting their personal safety.

According to a CMS Statement of Deficiencies and Plan of Correction report, actions by staff and law enforcement led to the tasing and handcuffing of a patient. The use of weapons and law enforcement in care settings is against CMS policy.

The quandary, however, is that the incident was preceded by the patient verbally threatening other patients, throwing a chair, and hitting a mental health worker in the head repeatedly.

CMS agreed to allow the hospital time until Aug. 29 to transition to new safety regulations that no longer include calling law enforcement to the units.

The Retreat’s ultimate goal is to “eliminate law enforcement’s involvement,” said Peter Albert, senior vice president of government relations and managed service organization.

Peter Albert, senior vice president of the Brattleboro Retreat. Photo by Randy Holhut/The Commons

Peter Albert, senior vice president of the Brattleboro Retreat. Photo by Randy Holhut/The Commons

Some patients who have been involuntarily committed through a court order and refuse treatment are violent to themselves and others, Albert said.

“We’ve been working on this for the last two years,” Albert said. “No one has a quick answer on that.”

Albert said the system is broken. He pointed to the length of time it takes to get a court order to medicate a patient involuntarily. That process can take up to 80 days, during which time a patient goes untreated.

Two years ago, when Tropical Storm Irene flooded the Vermont State Hospital in Waterbury, the Retreat opened its doors to displaced patients and VSH staff.

Since that night, the hospital has become one of four in the state providing treatment for state patients.

Last year, the Retreat received $5.3 million in state funds to upgrade its facility and create a 14-bed acute care unit. The hospital routinely cares for more than 14 state patients.

But treating patients with a higher level of acuity comes with challenges, including more violent behaviors. In addition the Retreat has come under more scrutiny from CMS, the state, and the press.

During its most recent investigation, CMS determined that on July 3, the Retreat violated the standards for patient rights regarding restraint and seclusion. The hospital also relinquished control of the situation to law enforcement.

As a result of this most recent incident and previous violations, the Retreat’s funding from the federal government is in jeopardy again.

If CMS pulls its certification of the facility, as it did with the Vermont State Hospital in Waterbury 10 years ago, the Retreat could lose a chunk of its funding. In addition, the state contracts with the Retreat for about $8 million a year to treat patients who are under the care and custody of the commissioner. Most of these patients are eligible for federal funding.

CMS has given the Retreat until Oct. 30 to meet a new plan of correction. CMS has given the Retreat two deadline extensions because its previous plans were not acceptable. The original deadline was Aug. 15.

A violent episode

CMS noted in its most recent report that although Retreat staff are trained to de-escalate patients’ behavior, staff chose in July “to request police assistance with the administration of the emergency medication.”

Federal investigators found that on one incident, Patient #1 had a diagnosis of schizophrenia, disruptive mood dysregulation disorder, and a recent history of a violent assault. When Patient #1’s behavior escalated, other patients asked staff members to intervene.

The attending psychiatrist initially ordered Patient #1 to be sent into seclusion but later reversed the decision, keeping Patient #1 with other patients. Patient #1 would view seclusion — placement on the Adult Low Stimulation Unit — as “punitive,” according to the report.

The next morning, Patient #1 attempted to pour coffee on the head of a mental health worker, who pushed the cup away.

The worker later told CMS during the agency’s July 16 investigation that Patient #1 “came in with repetitive blows, pummeling my head…his/her arms were coming in from both sides. There was no escape … thought I would lose consciousness.”

After Patient #1 refused Thorazine, the supervisor for Security Services and charge nurse elected to contact Brattleboro Police to help administer the medication.

Patient #1 then lunged at two Brattleboro police officers and was tased by an officer and handcuffed, according to the report.

“We are not equipped to handle a patient this size and strength,” the security supervisor told CMS.

The administration’s response

In an Aug. 2 letter Rob Simpson, president and CEO of the Retreat, announced to staff that the hospital was found to be in “non-compliance with federal regulations and conditions of participation […] by using police to assist in patient care.”

Simpson told employees they can no longer use police “as a supplement to a safety emergency on an impatient unit.”

“The police may only be called onto an inpatient unit when the hospital believes that a crime has been committed and the patient will be removed from the hospital,” Simpson wrote.

“This does not mean that charges for that assault may not be filed,” Simpson wrote.

Rob Simpson, CEO of the Brattleboro Retreat. Photo by Randy Holhut/The Commons

Rob Simpson, CEO of the Brattleboro Retreat. Photo by Randy Holhut/The Commons

The Retreat has met with the Brattleboro Police Department and has confirmed that officers will “not remove a patient from a psychiatric unit for assaultive behavior when that patient has a diagnosed mental illness.”

Instead, the hospital will employ additional security officers to assist unit staff.

Calls to police must be approved by the nursing supervisor and administrator on call.

“This will clearly be an extremely rare occurrence given the understanding in Vermont by law enforcement and the state’s attorneys that patients in psychiatric hospitals should remain in hospitals for treatment of their illnesses and not be placed in prison or community cells,” Simpson wrote.

Brattleboro police assisted Retreat staff with patients four times this year, according to Simpson. He described calls to the police to inpatient units as “infrequent.”

The Retreat will also increase its training on best practices for managing violence, increase staff participation in “code green” safety drills, start including “violence plans” as part of patients’ treatment plans, and produce debriefing reports to senior Triad leaders of each unit (the unit chief/lead physician, the clinical nurse manager, and the social work supervisor) on all incidences of violence to help staff debrief after incidents.

The goal with this training is to help all staff feel they have the tools to be in control of difficult situations and to feel safe, said Albert.

“The sooner we identify an issue and address it, the less the patient escalates and [the less] staff needs to call for back up,” said Albert.

The Retreat believed it had interpreted CMS’s policy correctly, said Albert. But subsequent phone calls with the agency proved that interpretation to be incorrect.

Concerns about staff safety

Simpson’s letter to staff has raised questions among Retreat employees who spoke with The Commons on the condition of anonymity.

The issue of staff safety rose to the surface last year during union contract negotiations.

After interviews with staff last year, The Commons investigated allegations that violence toward staff had increased. Police reports and workers’ compensation data confirmed those assertions.

The employees who spoke with The Commons said the state’s mental-health system is broken. Employees point to long waits for administering involuntary emergency medications to violent patients and the limited number of facilities providing transitional care for patients after they leave in-patient treatment like the Retreat.

The workers say the hospital has effectively nixed their ability to report an assault.

One employee said management is too focused on meeting CMS requirements and as a result, overloads staff with rules and regulations.

According to CMS’s guidelines, patients have the right to receive care in a safe environment and be free from restraint or seclusion. CMS allows patients to be restrained or placed in seclusion only to protect the immediate physical safety of patients, staff, or other people. The regulations seek to protect patients from restraint and seclusion imposed through coercion and discipline, or for convenience or retaliation by staff.

Federal regulators consider the use of weapons — Tasers, nightsticks, guns, handcuffs, pepper spray — as the purview of law enforcement and not appropriate in a hospital setting.

Comments

  1. Doug Gibson :

    So DCF’s 3Sqaures’ program’s error rates are soaring due to staff cuts that workers warned would lead to soaring error rates. When first making the staff cuts, DCF leaders at the time labeled the cuts part of the “modernization” of the administration of the state’s food stamp program. And now it’s looking more and more like the modernization of Vermont’s mental health system is bogged down under the weight of many of the very same issues that Vermont State Hospital staff (and Dr. Batra, the VT Psych Assn and several lawmakers) warned about more than a year ago.

    Maybe it’s time to start paying a little more attention to the voices of the people who know the job best? Privatization is not always the best course.

  2. rosemarie jackowski :

    This is a very important issue. Maybe it doesn’t have a good solution.. but we have to continue to try to improve things for everyone.

    Too often non violent patients in nursing homes are over medicated. That is another problem that needs attention and exposure. AND, to further complicate matters, Frontline recently did an expose’ of Assisted Living Facilities and reported that there are no regulations on them… even after some ‘accidental’ deaths.

  3. I am really having trouble with this whole issue! What am I missing? If someone is admitted “involuntarily” to a psych ward, they are by definition “a danger to themselves or others”, I believe, and should be immediately medicated!
    I would not be here today as a free, fairly normal human being, if I had not been medicated back in 1971 when I, too, was diagnosed as having schizophrenia. That dx. has since been changed to PTSD. I do believe that medication can be overdone or included for far too long. But, as someone whose life was saved by medication, even though my blood pressure went down to almost kill me, there are times when being a danger to ones self or others takes primary importance. It certainly was not a fun experience! This all happened out of state, and I have had lots of talk therapy since, so I guess my story does not help the current controversy…

    • Curtis Sinclair :

      Many of those “dangerous” patients admitted involuntarily had very minor charges such as hitchhiking on the interstate, throwing a rock through a window or locking themselves naked outside of a motel room. Many don’t need to be drugged at all. Many received wrong diagnoses and were given the wrong medications as a result. I saw people’s lives destroyed by ‘medication’. The side effects can be debilitation and even deadly.

      While at the Vermont State Hospital I saw staff often times provoke patients into anger. I even heard some staff brag about it. It came as no surprise to me years later when VSH got decertified and found guilty of violating patients civil rights.

      Now it looks like the same horror show is being recreated at the Brattleboro retreat. It’s time to take a new direction and end all involuntary treatment.

  4. rosemarie jackowski :

    It is important to remember that psychology and therapy are not sciences. At best, they are a ‘healing’ art… sometimes helpful, sometimes harmful. Check out the Courtroom testimony of the psychologist for the Defense in the Jodi Arias case. No science there.

    Neuroscience might be more reliable. But even there, we have a long way to go.

    Restraining and medicating anyone against their will is a serious violation of human rights. Where there is violence toward others, it is sometimes necessary. Every case is different. No diagnosis is infallible. Very difficult issue, with no easy answers.

  5. Curtis Sinclair :

    I had two psychiatrists admit to me privately that they gave people antipsychotics to avoid getting sued rather than for any possible medical benefit to the patient. That is common practice in psychiatric hospitals. The best way to stop it is to eliminate involuntary treatment altogether.

    • Donna Hames :

      Curtis, I was an RN manager at the Retreat for many years. VT is a tough state to get involuntary commitment and it is always done only when a person presents a real threat to self or others.

  6. David Dempsey :

    Involuntary treatment of mental patients is an issue, but this story in not about giving involuntary treatment. It is really the opposite. These patients have refused treatment and must be housed and cared for by court order. It will take 2 to 3 monthes before a court order approving or denying involuntary medication is received. The sites that now house the most violent patients don’t have the necessary security staff for this type of patient. Before the flood, these patients were sent to the state hospital in Waterbury, where they had a trained security staff to deal with violent patients. The care givers at the sites around the state normally haven’t had to deal with this type of patient. If the new state hospital is big enough to handle all of these patients, the security staff there will be trained to deal with violent patients. But as long as other sites have to deal with violent patients, the state needs to hire trained security staff for each site.

  7. Curtis Sinclair :

    Most likely the patients have been refusing medical malpractice, not treatment. They likely had some kind of kangaroo court hearing with inadequate legal help which resulted in them getting admitted to the hospital. I saw a guy at VSH who was there for 6 months after he stole cigarettes. Of course many patients are angry. Then the staff goad them into outbursts and then they can label all mentally ill people as potentially violent ‘psychos’ who all need to be given massive doses of debilitating drugs.

    At VSH I saw a patient get yelled at and then tackled by a 300 pound staff person for bringing a cup of milk out of the dining room without a lid. Situations like that would be defused easily if involuntary treatment was eliminated. Patients would simply check themselves out of the “horror hotel”. The ‘violent criminal charge’ against the guy with the uncovered milk was hitchhiking on the interstate. He would have gotten a night in jail for that. Instead the mental health system ‘helped’ him bu locking him up for months, force drugging him, and violently restraining him when he got angry. It looks like the same thing is happening at the Retreat.

  8. David Dempsey :

    Curtis,
    It is easy to see that you are a very disgruntled former VSH employee. I understand your frustration with the way patients are treated. It sounds like your solution to the problem of violent patients who are involuntary put in the hospitals by the courts and are waiting for the decision to be made about involuntary treatment would be to not put them in the hospital in the first place. That would eliminate the need for security people trained to work with violent patients. Does that mean that you are confident that these mentally ill people are not a threat to themselves or others? I was a patient at the NH state hospital 11 years ago. I was talking with anothe patient when a women walked up behind him and drove a pen into his shoulder. There was alot of blood and he was hurting. I don’t know why it happened or what happened to him and the lady, I didn’t see either one after that. But I was glad that 2 guys who looked like linebackers were right there in what seemed like seconds because she was looking right at me.

  9. Curtis Sinclair :

    If someone has broken a law let the criminal court handle the situation. Offer them mental health treatment on a voluntary basis only. I knew many people who would have rather been in jail rather than in the mental health system, but they weren’t allowed to make that choice. One guy had to stab his lawyer in the neck with a pencil to get the judge to assign him a new lawyer. He had wanted a lawyer who would help get him found competent on his criminal charge so he could stay out of the hospital, but the judge denied it. His logical alternative was to stab the lawyer he didn’t want in the neck. That should not have to happen.

    According to Thomas Szasz, a well known psychiatrist and academic: Just as legal systems work on the presumption that a person is innocent until proven guilty, individuals accused of crimes should not be presumed incompetent simply because a doctor or psychiatrist labels them as such. Mental incompetence should be assessed like any other form of incompetence, i.e., by purely legal and judicial means with the right of representation and appeal by the accused.

    Also: No one should be deprived of liberty unless he is found guilty of a criminal offense. Depriving a person of liberty for what is said to be his own good is immoral. Just as a person suffering from terminal cancer may refuse treatment, so should a person be able to refuse psychiatric treatment.

  10. Dave Bellini :

    Wow. What a horrible place to work! Employees get assaulted and the management doesn’t back them up. I don’t think workers check their constitutional rights at the front door. They have the right to be safe. They have the right to protect themselves from bodily harm. They have a right to call police if they are being assaulted. The Retreat has no clue what to do and shouldn’t be in the business of housing violent people. If employees can’t be protected any better than this, then the Retreat should get new management that is capable and makes safety the number one priority.

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