[B]RATTLEBORO — A state inspection found multiple violations of patient rights and emergency services standards at Brattleboro Memorial Hospital, including an instance of “unnecessary force” used when police were summoned to subdue a mental health patient, new documents show.
The state Division of Licensing and Protection also found that the hospital’s Emergency Department staff prematurely resorted to physical restraints — and then failed to remove them in a timely manner — when treating another patient diagnosed with mental illness.
State documents show that hospital administrators are implementing a detailed plan to address the issues. Changes include revamped policies, additional monitoring and increased staff education; the hospital also has reached out to police and other health care providers in the area.
The state’s investigation happens under the auspices of the federal Centers for Medicare and Medicaid Services. Violations that go unaddressed can lead to a facility becoming ineligible for Medicare and Medicaid funding.
“The corrective action plan in response to this incident was built upon the continuous quality improvement initiatives already in development and in place at BMH,” hospital administrators said in a statement Tuesday. “We take every patient complaint as an opportunity to review and strengthen our existing policies, processes and relationships with our external partners.”
A spokeswoman said hospital administrators were unavailable for further comment Tuesday.
Some outside the hospital say the situation underscores the state’s ongoing struggle to meet the demand for mental health treatment. The state report says one of the patients remained at Brattleboro Memorial’s emergency room for a week “due to the lack of availability of a psychiatric admission bed.”
“There’s a breakdown in the system,” said Brattleboro Police Chief Mike Fitzgerald. “A person suffering from a mental health crisis doesn’t belong in the ER. They belong in a mental health facility where they would get the care that they need.”
Two patients are key
The state scrutiny and subsequent corrective action have played out over the past few months at Brattleboro Memorial, a 61-bed hospital that serves a population of 55,000 in Vermont, New Hampshire and Massachusetts.
The Division of Licensing and Protection completed a survey of the hospital’s operations March 24. Suzanne Leavitt, the division’s assistant director, said the survey was prompted by several complaints alleging incidents at the hospital.
In their report released Tuesday, state officials focus on the hospital’s “failure to provide sufficient interventions to assure each patient’s rights are protected.” That happened, the state contends, in a number of ways — mostly involving people identified as Patient No. 1 and Patient No. 2.
Patient No. 2 was admitted in early January, seeking treatment for depression, anxiety and suicidal thoughts. An emergency staffer initially described the person as stable and cooperative, but the patient became angry and tried to leave when informed that “a specific psychiatric facility s/he had requested for admission had no beds available,” the state’s report says.
Brattleboro police were summoned several times over the course of several hours, and the patient returned to the emergency room each time. But the patient then became “verbally assaultive” to staff, tried to push past security and attempted to break a glass door, documents say.
Police again responded and took charge of moving the patient to another room. After the patient refused to move, police placed him or her in a “noncompliant escort hold,” state officials say.
When the patient resisted and tried to kick an officer, police used a takedown move that involved pinning the patient’s head to the floor, the report says. Officers eventually handcuffed the patient’s right wrist to a bed, and state officials say hospital staff didn’t document how long the patient stayed handcuffed.
Fitzgerald acknowledged that such police action “sounds harsh.” He cited the unpredictability and volatility of a violent mental health situation, when police officers must balance the safety of the patient with “the safety of everybody who is around them.”
At the same time, Fitzgerald said police are “making great strides in trying to de-escalate situations” involving mental health patients. “We are mandating training for all of our officers,” he said. “We have a mental health worker in the department.”
The state report does not specifically find fault with Brattleboro police; rather, inspectors say hospital staff erred in “relinquishing the decision-making process to police officers for managing the room transfer of Patient No. 2.”
Staff “failed to follow hospital policy when allowing the police to use physical force, manual restraint and the application of handcuffs to a patient requiring psychiatric hospitalization who was not under arrest or in police custody,” the report says.
The other person cited most often in the state’s inspection findings — Patient No. 1 — was admitted to Brattleboro Memorial’s Emergency Department on Dec. 31 and stayed until Jan. 6. Despite a diagnosis of psychosis and a need for “psychiatric hospitalization,” there was apparently nowhere to send the patient.
The documentation of problems and disruptions caused by the patient during that time is extensive. Those included “persistent wandering,” screaming, writing in blood on a wall and assaulting a nurse.
When hospitals restrain or seclude a patient, that should happen only “to ensure the immediate physical safety of the patient, a staff member or others, and must still be discontinued at the earliest possible time,” state officials say. For Patient No. 1, those principles allegedly were not followed.
On Jan. 2, the report says, emergency staff “failed to discontinue the use of four-point restraints at the earliest possible time” even though the patient had calmed down. In another incident two days later, “there was no evidence (the) least-restrictive methods were attempted prior to the application of restraints.”
Generally, state officials say the hospital “failed to effectively analyze and evaluate the appropriateness of restraint/seclusion use” in the emergency room. As a result, there was “a failure … to identify additional opportunities for improvement” in those areas at Brattleboro Memorial.
Staffing also was cited as an issue: The state report says the hospital “failed to assure sufficient staff coverage was available at all times in the (Emergency Department) to provide essential services and to respond to emergent events or procedures.”
In a March 16 interview with the state, the Emergency Department manager reportedly said that “night resources are slim” in the unit and law enforcement is used as a “backup” and a “show of force.”
Other problems mentioned in the report include a failure to address a potential safety hazard and a failure to keep adequate records; in each case, the issues affected two patients.
A plan for improvement
Documents show that Brattleboro Memorial Hospital is attempting, in a variety of ways, to respond to the state’s concerns. For example:
• Emergency staff have received instructions on the use of seclusion and restraint as well as behavioral management, room safety checks and patient searches/contraband.
• Nurses and their supervisors are being trained “regarding the appropriate interactions between hospital staff and law enforcement staff on the BMH campus.”
• Meetings have taken place between hospital staff and the Brattleboro Police Department, the Windham County Sheriff’s Department and the state Department of Mental Health. That state agency also has analyzed the restraint policies of both the hospital and the sheriff’s department and made recommendations to align the two.
• The hospital now has a modified “Code Green” policy for using law enforcement to help manage emergency patients.
• Hospital administrators have been reviewing all cases of patient seclusion and restraint and talking about any issues with the personnel involved in those cases.
• Brattleboro Memorial administrators also are meeting with other care providers in the area. The goal is to improve behavioral health care. Topics for discussion include information sharing, care planning and transitions, and telemedicine.
Ultimately, it will be up to the state Division of Licensing and Protection to determine whether hospital administrators have taken adequate action, or further improvements are needed to meet federal health care standards for Medicare and Medicaid reimbursement.
“We’ll do a state follow-up, unannounced,” Leavitt said.
