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.
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.
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.
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.