The most recent federal survey of the Brattleboro Retreat psychiatric hospital found staff failed to follow protocols in three instances in September; in one of them, a patient nearly drowned.
On Sept. 22, a 16-year-old patient with bipolar disorder and acute mania, who was supposed to have constant monitoring with staff no more than an arm’s length away at any time, was allowed to bathe alone behind a closed door, according to the survey report. A nurse found the patient unresponsive in a bathtub.
The incident happened on the Tyler 3 adolescent unit, where there have been two suicide attempts in the last six months
The parents of one of the patients maintain she died from self-inflicted injuries six weeks after she tried to hang herself at the Retreat.
In the September incident, the patient was found face down in the water and was quickly removed from the tub by a mental health worker who should have been in the room with the patient.
The patient was initially unresponsive, but was revived after a “sternal rub” and began coughing up water. The patient was later seen by medical staff, and no “functional limitations” are noted in the patient record, according to the survey.
Despite the patient’s significant psychiatric illness requiring “continuous observations for the purpose of keeping the patient safe, staff failed to follow hospital policy and physician orders resulting in a near drowning of the patient,” the survey states.
Retreat officials said they aren’t calling the incident a suicide attempt, because they don’t know if the patient intended to harm him/herself, said Konstantin von Krusenstiern, vice president of strategy and development.
“Regardless of that, the staff person either clearly [sic] misunderstood the physician order or chose to apply his/her own judgment,” he added, in an email.
In either case the staffer made the wrong decision, von Krusenstiern said. The Retreat has submitted a plan for corrective action to the Centers for Medicare and Medicaid Services (CMS) that includes steps to improve communication and ensure that physician orders are followed, he said.
“This was a very ill 16-year-old patient in our state care and custody for treatment, who came within seconds of drowning despite months of concern about suicide attempts on that very unit,” said Rep. Anne Donahue, R-Northfield. “These latest revelations underscore the depths of the systemic problems, and the risks to patients, that have been evident for so long now.”
“We are all exceedingly fortunate that there was not another death,” Donahue added.
The incident happened just days before state surveyors acting on behalf of the CMS made an anticipated but unannounced site visit to the Retreat.
Retreat officials said that it was clear from the exit interview with surveyors on Oct. 1 that the hospital was not in compliance with the conditions for participation in Medicare and would lose its federal certification.
Gov. Peter Shumlin called the regional director of CMS and helped to broker a deal to prevent the hospital being decertified, according to Secretary of Administration Jeb Spaulding.
The Retreat’s potential inability to bill for federal subsidies, he said, would be a “disastrous situation.”
Spaulding, who participated in the call, said the administration wasn’t trying to give the Retreat a pass. He said the governor wanted to ensure that CMS officials understood how decertification would impact the region.
The Retreat has Vermont’s only inpatient child and adolescent psychiatric units, and provides mental health and substance abuse services to the state funded by Medicaid. The mental health services alone total $8 million, and if the Retreat were decertified, it would not be eligible for Medicaid funding.
In addition, Medicaid beneficiaries in Vermont and other states that seek voluntary psychiatric or substance abuse treatment at the Retreat would not be able to use that coverage, Spaulding said.
Shumlin was aware of the latest patient harm incident at the Retreat when he made the call to CMS on its behalf, according to Sue Allen, a spokeswoman for the governor.
“The governor has been aware of the Retreat’s challenges, including these recent incidents, but feels strongly that the state should work with the Retreat to help ensure compliance with federal CMS guidelines so that the Retreat can continue to serve those in need,” she said in an email.
The Retreat’s plan for corrective action was submitted to CMS on Oct. 16. That plan won’t be public until CMS accepts or rejects it. CMS has approved the Retreat’s two most recent correction plans submitted over the summer and fall.
The Retreat will lose its certification on Nov. 1 if the plan is not accepted, and to avoid losing its certification based on the latest survey findings, it has agreed to enter a Systems Improvement Agreement with CMS to address the persistent patient safety and care quality issues.
That agreement entails a protracted period of oversight, as long as two years, during which the Retreat must hire a CMS approved consultant to help them make lasting changes to patient care practices.
Sustained federal involvement is a “positive step” toward rebuilding quality oversight at an important Vermont institution, Donahue said.
At a Mental Health Oversight Committee meeting Friday, Department of Mental Health officials said they are meeting regularly with Retreat officials and are “actively engaging and providing input” on the development of a corrections plan and the broader Systems Improvement Agreement.
Paul Dupre, the commissioner of the department, said the Retreat must take steps to improve its patient care practices, but no quality improvement can ensure the safety of acute psychiatric inpatients in all situations.
The Retreat handles patients who have severe cases of mental illness, and tragedies occur there that are beyond the control of caregivers. The hospital was cleared of any liability for a teenager’s death by suicide in January at an outpatient facility it operates.
The Oct. 1 survey also found that a patient with a history of suicidal behavior got hold of a length of spandage, a tubular elastic dressing material, and used it in an attempted self-strangulation in the presence of staff.
Staff was able to wrestle the spandage from the patient, and were admonished not to dispense a length of more than two inches. However, a state surveyor demonstrated that the spandage at any length, because it is tubular, can be placed around the neck and used for strangulation.
The Retreat has agreed to stop using spandages for its patients.
In a third incident in September, staff again didn’t follow protocol for the care of a patient with schizophrenia and delusions who was not properly monitored and escaped from the hospital. The patient was quickly found by security staff and voluntarily returned to the hospital.
