BELLOWS FALLS — In late May a patient at the Windham Center mental health facility was left in restraints for nearly 12 hours and was coerced into taking medication, according to an investigation report from the state.
Federal law allows patients to be held in restraints for up to four hours with a written order from a physician. The patient, who was “angry … agitated and grossly delusional” and “threatening to assault staff,” was held in restraints from roughly 6 p.m. on May 27 until 5:47 a.m the following morning.
Psychiatrist Theodore Miller refused to let the patient out of restraints unless the patient took an antipsychotic medication, despite laws that ban the use of restraints for coercion, discipline, retaliation or convenience.
Just after 10 p.m., “Dr. Miller told patient that if s/he took medication we would allow h/her out of the restraint to go to the bathroom,” according to nursing records quoted in the report.
The patient asked repeatedly to use the bathroom and was told by nurses to urinate in the restraints, which the patient eventually did, according to the report.
From just after 10 p.m. until the patient was released there is no record in the state’s report of additional physician orders being signed.
The Windham Center has since submitted a plan of correction to the state Division of Licensing and Protection and the federal Centers for Medicare and Medicaid Services, which was accepted Aug. 19.
The correction plan states all staff will review and sign the facility’s restraint and seclusion policy. It states that “A written physician order to continue restraint will be provided each 4 hours during duration of restraint use,” and that “Coercion will not be utilized to facilitate restraint removal.”
Including subheadings, the entire correction plan is 251 words.
Springfield Hospital, which operates the Windham Center, did not respond to requests for comment Wednesday.
The letter accepting the correction plan notes that there could be an unannounced follow-up visit to ensure the plan is implemented and working.
The Windham Center takes patients in state custody and, as a result, the Department of Mental Health has oversight responsibility for the facility.
The May 27 incident at the Windham Center is the third high-profile incident at a psychiatric facility in the past six months at locations overseen by the department.
“Are they responding and just not telling the Legislature, or are they not responding at all?” asked Rep. Anne Donahue, R-Northfield, a member of the Joint Committee on Mental Health Oversight.
“I don’t know the answer to that question, but I think it’s an important one,” she added.
Donahue said she was not aware of the May 27 incident at the Windham Center, but said it’s “coming on the heels of them having similar problems that they were supposed to have corrected.”
She was referring to incidents in 2013 that triggered CMS and state investigations.
Frank Reed, deputy commissioner of the Department of Mental Health, said his department was not aware of any incidents at the Windham Center or Springfield Hospital until Donahue raised them at a July meeting of the Mental Health Oversight Committee.
Reed said it’s unacceptable for a hospital designated to treat patients in state custody to not inform the department of investigations or the resulting findings. The department has sent a letter to the hospital saying as much, he added.
Reed says it was not an intentional failure by Springfield Hospital to notify the state, but rather a result of the infrequency with which it does inpatient care for the state.
The department’s quality management unit has reached out to the hospital and will help it get back in compliance with state and federal regulations, Reed said.
Other than “this glitch with the Windham Center,” the state is on top of its oversight duties and has done the necessary reporting to the Legislature, he said.
The department is only required to report events to the Legislature that occur at hospitals, hence lawmakers were not told about a recent escape attempt at a secure residential psychiatric facility in Middlesex.
Previous problems at the Springfield and the Windham Center
In February, Springfield Hospital and the Windham Center ran afoul of the state and CMS for a December incident in which they transferred a psychiatric patient in state custody from the Windham Center to the hospital’s emergency department because of staffing concerns, not because it was the appropriate location for treatment.
The patient remained in the emergency department for eight days, according to the investigation report. The state paid sheriff’s deputies to attend the patient for the much of the time.
Vermont has spent more than $1 million to have sheriff’s departments look after the mentally ill boarding in emergency departments since July 2013.
Just days before the patient was transferred, a Springfield Hospital emergency department doctor testified before a legislative committee about how disruptive it is to have people with mental illness boarding in his department.
Another patient was transferred without proper cause from the Windham Center to the Springfield Hospital emergency department in February 2013, according to the state report.
The patient who was involuntarily held in restraints by doctors and nurses in the May 27 incident said in the investigation report that the experience was traumatizing and the patient felt “a line was crossed.”
The patient eventually agreed to take antipsychotics after nearly half a day in restraints and one hour after urinating on him- or herself.
The patient was then allowed to take a shower and have a cigarette, the report says.
CORRECTION: The date of a second incident where a patient was transferred to the Springfield Hospital emergency room was incorrect in a prior version of this story.