A rash of new regulatory findings detail mistreatment of psychiatric patients at Vermont hospitals, raising questions about treatment standards in the state’s overtaxed mental health system. This story is the first in a three-part series on psychiatric treatment in Vermont hospitals.
[F]or 11 days in late summer, nurses at Northeastern Vermont Regional Hospital maintained a delicate detente with a person identified in state documents only as “Patient No. 1.”
Staff at the St. Johnsbury hospital saw a mental health patient engaging in an escalating pattern of “intrusive and threatening behaviors” while refusing medication. But the patient faced an all-too-familiar dilemma in Vermont – being involuntarily committed for psychiatric care, but stuck in a place that couldn’t provide it.
Meanwhile, contracted law enforcement officers waited nearby even though the patient had “expressed dislike for individuals in uniform.”
Late on Sept. 2, those tensions erupted into an all-out brawl.
As staff tried to apply restraints in order to administer medication, the patient hit a law enforcement officer in the head. Both fell to the floor, and the officer punched the patient in the face. Another officer delivered blows with a baton as the patient tried to reach for a police weapon.
The melee ended only when a third officer shocked the patient in the upper torso with a stun gun.
Two days later – and 13 days after first arriving – the patient finally left Northeastern for a psychiatric hospital.
The Northeastern incident is just one in a series of serious deficiencies reported in 2018 by Vermont regulators as they examined hospitals’ treatment of mental health patients. A VTDigger examination of records recently made available by the state showed regulatory violations involving 18 mental health patients at six hospitals cited in inspections performed over the past nine months.
Mental health patients mishandling in VT since late 2017
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Hospitals have scrambled to add new staff, programs and policies to deal with mental health patients who are streaming into emergency rooms. And psychiatric units are operating at near-100 percent capacity to try to ease the pressure on emergency rooms.
But the latest state complaints show that, too often, patients aren’t getting the care they need.
“The reason why we come into this profession is to care for patients and to do the right thing for the patients,” said Seleem Choudhury, chief nursing officer at Northeastern. “So it takes a toll on the provider when you see patients who come in who clearly need to be somewhere else, and they’re not.”
“You can’t help but feel that mental health as an illness is not treated the way it should be treated in the United States of America – actually, it’s not treated the way it should be treated in the western world,” Choudhury added. “And that needs to change.”
Physical struggles like the one that marred Patient No. 1’s treatment at Northeastern were frequently noted in the state Division of Licensing and Protection reports. But they were far from the only problem: In other cases, documents show that restraints were improperly applied or left on too long; patients staged repeated escape attempts; police were used in the administration of involuntary medication; and employees were not adequately trained.
The state’s findings
Among the deficiencies that were identified:
• A February report faulted University of Vermont Medical Center for failing to ensure “care in a safe setting” after two patients repeatedly fought on a psychiatric unit over two days. One patient suffered a traumatic eye socket injury and the other required staples to close a head laceration.
• In March, a state survey found that the Brattleboro Retreat “failed to ensure that seclusion and restraint were implemented appropriately and safely” when a 75-year-old patient was repeatedly restrained, isolated and given involuntary medications – one of which caused a reaction that led to a cardiac emergency.
• Northeastern was also the subject of an April investigation in which a juvenile mental health patient with previous escape attempts bolted from the emergency department and didn’t return for 28 hours. The patient had no coat in cold late-March temperatures.
• Copley Hospital in Morrisville was cited in a May report blaming a lack of adequate, trained staff for two incidents: One mental health patient was handcuffed for 20 minutes by a police officer, and another was restrained by staff for nearly seven hours even though the patient had become “calm and cooperative” and fell asleep.
• Inspectors returned to Northeastern in June and found that a psychiatric patient who was “aggressively suicidal” had escaped the emergency room in May. A law enforcement officer “physically subdued” the patient in the parking lot and applied handcuffs.
• In July, regulators noted that a patient at Vermont Psychiatric Care Hospital in Berlin had attempted suicide by hanging. Officials found that staff hadn’t been following policy to search rooms on a weekly basis, and there “was no organized plan” to remove potentially dangerous materials identified in the incident.
• A September investigation at Northwestern Medical Center in St. Albans found multiple problems including police officers called in for the purpose of “showing presence” so that uncooperative patients would take their medication.
Actions like that, some say, were clearly taboo years ago.
“Don’t these hospitals talk to each other? Don’t they know you’re not permitted to use police officers for health care delivery?” asked Anne Donahue, a state representative and interim executive director of Vermont Psychiatric Survivors. “This is old stuff. How can this be happening again?”
The answer, in part, may lie in the sheer number of psychiatric patients stuck in medical hospitals – and their increasingly lengthy stays.
Patients numbers growing
Hospitals are reporting double-digit annual increases in the number of mental health patients entering emergency facilities. A statewide snapshot earlier this year from the Vermont Association of Hospitals and Health Systems showed that the number of days psychiatric patients spent in emergency departments climbed from 3,138 in 2015 to 5,237 in 2017 – a 67 percent jump.
That report also showed that patients are staying longer. From 2015 to 2017, same-day discharges of mental health patients dropped while emergency room stays of one to 10 or more days increased.
The problem is the same no matter the size of the hospital and no matter whether there are psychiatric beds on site.
At the 25-bed Porter Medical Center in Middlebury, where there are no psychiatric care facilities, 37 mental health patients waited an average of 40 hours in the emergency room in fiscal 2017.
The 447-bed University of Vermont Medical Center in Burlington – where there is a dedicated psychiatric unit – reports that 656 patients waited in the emergency room for a mental health bed between May 2017 and April 2018. The average wait time was a few days, though some stayed for weeks.
What’s behind this?
What’s not yet clear is why this is happening, though a lack of inpatient mental health beds is one obvious factor.
Though the state has rebuilt treatment capacity since Tropical Storm Irene closed the Vermont State Hospital in 2011, recent projections estimate that the state may need another 29 to 35 such beds to meet current and future needs. State officials are working with the Brattleboro Retreat and UVM Health Network to develop more bed capacity.
But those projects take time, and no one is convinced that adding more beds is the only or best answer.
“I think if it was that simple, we wouldn’t be dealing with it like we are,” said Mourning Fox, interim commissioner of the state Department of Mental Health.
Fox, who has been trying to address the emergency department issue throughout his six years with the department, says a “confluence of factors” is fueling the problem.
“It’s about resources in the community. It’s about inpatient capacity. It’s about our ability to have diversion capacity – having more crisis beds and other diversions to help prevent crises from rising to the point of needing hospitalization,” Fox said.
He also noted a common theme in recent mental health discussions at the state level: Not only are more mental health patients showing up at hospitals, they’re also staying longer because of increasingly acute illness.
While Fox says that’s “not a Vermont issue alone,” he and others also say there’s no clear reason why it’s happening.
Higher stress levels may be one issue, and the opioid-addiction epidemic may be playing a role. But overall, Fox said, “I don’t think there’s a general consensus right now as to … why are people sicker now than they used to be. I’ve seen everything from the influence of lead paint to just kind of the general political climate of the country. But I have yet to see something that scientifically has been able to pinpoint, ‘Here’s the reason.’”
Smaller facilities especially stressed
What is clear is that psychiatric patients present challenges that many medical hospitals are ill-equipped to deal with.
“The takeaway from (the state inspection reports) is, smaller hospitals that don’t have psychiatric units apparently don’t have the depth of training … in how to respond to folks in the emergency department with mental health conditions,” said A.J. Ruben, supervising attorney for Disability Rights Vermont.
It’s not just a training issue. In a statement issued in response to questions from VTDigger, Copley Hospital Chief Executive Officer Art Mathisen acknowledged that the Morrisville facility “is not staffed or equipped … to provide the therapeutic care and/or determine needed medication or medication changes for patients in psychological crisis.”
“This puts the patient in a holding pattern,” Mathisen said. “We keep them safe, try to keep them calm and comfortable until the crisis team arrives and/or a bed in the right facility for them opens up. At times, if the person is violent, our focus is on keeping both the patient and our staff safe. We try to really work with the patient, to follow their preferences, protect their dignity and be respectful.”
But when things go wrong, that leads to regulatory trouble.
The state Division of Licensing and Protection conducts “unannounced surveys” – sometimes prompted by complaints – to ensure health care facilities are complying with state and federal regulations. The federal inspections happen on behalf of the Centers for Medicare & Medicaid Services, so a hospital’s government funding can be at stake if serious deficiencies go uncorrected.
So the division’s mental health-related findings this year prompted a flurry of so-called “plans of correction” at Vermont hospitals.
At Copley, for instance, state documents show that a patient arrived at the emergency department in April suffering from suicidal thoughts with “associated agitation and anxiety.” After an initial attempt to leave, the patient was placed in police handcuffs for 20 minutes; after a second attempt, “staff and two police officers applied leather restraints to secure Patient No. 1’s extremities to the bed.”
This happened even though the patient “was not under arrest nor had been charged with a crime.”
Copley’s plan of correction included educating staff on proper emergency responses and revising a policy to clarify that “non-employees may not be involved in patient care services.”
Multiple incidents at Northeastern
Northeastern’s several run-ins with state Licensing and Protection inspectors started with a juvenile patient threatening self-harm in March. The patient was in need of mental health treatment but stayed “because no psychiatric beds were available.”
On March 27, the juvenile twice tried to leave the emergency department, screaming, “I’m not going back in that room.” The patient was successful on a third escape attempt, running through a back door and across a parking lot before disappearing into the trees.
“Patient No. 1 was not wearing outerwear, (and) local temperatures in this rural area registered between 34-43 degrees,” the state’s report notes. The patient returned the next day; there was no report of any injury in state documents.
Among other issues, the state said Northeastern had “failed to develop an emergency safety plan which incorporated immediate interventions” and failed to provide enough trained staff to ensure “appropriate monitoring to ensure the safety of the juvenile.”
In addition to that escape and a second escape attempt in May, Northeastern also was cited for the September fight that ended with stun gun use as well as multiple instances where restraints were improperly used on psychiatric patients.
The hospital undertook policy revisions including “use of weapons on individuals not in custody of law enforcement.” But in a written response to the state, Northeastern also defended the actions of staff and law enforcement in the fight incident, saying a sheriff’s deputy’s presence was needed “to protect staff from harm.”
And on the topic of restraints, the hospital underscored the volatility of “verbal threats and physical challenges” posed by mental health patients.
“Use of restraints, both chemical and physical, is a measure of last resort when all attempts at de-escalation have failed, placing the patient, staff and others at risk for harm,” administrators wrote.
Police presence can have serious effects
From her position as a mental health advocate, Donahue said her problem is with the way some hospitals are using restraints.
“Nobody’s saying you can’t restrain somebody at the moment they’re out of control,” said the Northfield Republican House member. “But then when they’re asleep, then you don’t keep them restrained. That’s inhumane.”
Humane treatment, Donahue said, also means “not having police called to address your illness because staff don’t know how to address your illness.”
That’s a reference to one of Northwestern Medical Center’s regulatory issues. A person identified in state documents as “Patient No. 3” entered the St. Albans hospital in early September with a bipolar diagnosis and “a history of noncompliance” including “erratic and severe agitation requiring emergency intervention by law enforcement.”
Stuck in the emergency department for 10 days, a variety of problems ensued, including issues with restraints; unsafe items left in rooms; and inappropriate behavior by a visitor. The state also documented the presence of three St. Albans police officers and two county sheriff’s personnel in the patient’s room during the administration of involuntary medication.
A hospital staffer later told investigators that police were called for the purpose of “showing presence” during medication administration. And while the hospital’s chief nursing officer told the state that police “were not utilized to manage patients,” the emergency department’s nurse manager said that, “generally when the police walk into the department, patients tend to change their actions.”
That incident and others earned not only the state inspection report but also a letter from CMS officials warning that termination of federal funding for Northwestern “can only be averted by correction of the deficiencies.”
In a prepared statement sent to VTDigger, Dr. John Minadeo, Northwestern’s emergency department director, said emergency rooms “are not equipped to provide the proper care that these patients deserve. They require a very specific set of skills and facilities that a typical emergency department is unable to provide.”
That being said, Northwestern’s plan to correct inspection report deficiencies “has been accepted by CMS and has been implemented at the hospital,” said Jonathan Billings, the hospital’s community relations vice president.
“We have updated policies and procedures, we are providing additional training and education and we are conducting ongoing auditing and monitoring of process and procedures related to patients with restraints,” Billings said. “(The hospital) is currently waiting for a follow-up visit from CMS and are confident we have met their expectations.”
Psychiatric care facilities not immune
While the public’s focus has been on mental health patients stuck in emergency rooms, the state’s regulatory scrutiny also has extended this year to facilities designed specifically for psychiatric care.
In addition to the patient fights cited by inspectors at UVM Medical Center’s Shepardson 6 psychiatric unit, the state also found that the hospital left five patients in seclusion for too long. UVM’s corrective actions included enhancing safety plans and revising its restraint policy.
UVM Medical spokesman Michael Carrese said patient concerns prompt “a thorough review to determine the cause and to develop an improvement plan.”
“We’re confident that through our collaboration with the state, ongoing monitoring from experts in our Jeffords Institute for Quality and involvement of our nurse and physician quality leaders, we have the right policies and procedures in place to deliver the highest level of care to patients in these circumstances,” Carrese said.
State inspectors also found problems earlier this year at the Brattleboro Retreat.
Like the findings at UVM and Vermont Psychiatric Care Hospital, the Retreat case involved violations that were less serious than “condition”-level findings that can jeopardize funding. Nevertheless, the state’s report calls attention to an older Retreat patient – who was confused and “expressing concern about who would provide care to his/her cat” – being restrained, secluded and medicated multiple times.
The patient’s behavior included “being anxious and aggressive towards staff” and entering the nurses’ station. But state inspectors found that the patient suffered a “cardiac emergency” due to psychiatric medication; was left with bruises and pain due to restraints; and remained in “locked-door seclusion” for too long.
In response to an inquiry from VTDigger, a Retreat spokesman said the hospital “is wholly committed to continuously improving the systems and procedures for providing safe, quality care for our patients.”
Fox took a similar approach to the Vermont Psychiatric Care inspection report. Regulators focused not on a patient’s attempted suicide at the state-run Berlin hospital, but rather on safety measures that didn’t occur before and after that event.
The type of locking nylon ties used by the patient were removed from the hospital soon after the incident, Fox said.
Though staff members weren’t faulted directly in the suicide attempt, “the reality is, we still have deficiencies. And so we still need to deal with those deficiencies,” Fox said. “We’re not here just to meet the CMS standard. We’re here to provide good clinical care.”
Searching for solutions
Attempts to improve care for mental health patients are taking a variety of forms, and the effort goes beyond the steps outlined in hospitals’ mandatory “plans of correction.”
As the number of psychiatric patients at their front doors continues to increase, medical hospitals have built special accommodations. Northwestern is the latest to undertake such a project, telling the Green Mountain Care Board in this year’s budget submissions that two planned “behavioral health patient rooms” incorporated into the emergency department in St. Albans “will support the safe care of these patients … while awaiting transfer to more appropriate facilities.”
Hospitals such as Northeastern also are adding trained mental health staff to their emergency services, though that can come at a steep cost. One way to lessen those costs is to contract for remote telepsychiatry services, allowing faster access to mental health consultations.
Ruben, at Disability Rights Vermont, sees a need for more trained staff including peer supports for mental health patients. “It’s not clear that the Department of Mental Health or the Department of Health have taken full advantage of their ability to provide training and resources to these small emergency departments,” Ruben said.
Fox said some of that training has begun to happen over the past year or so, and that will continue. “I think it’s important that everyone’s operating off of the same information, and that we’re all on the same page,” Fox said. “So I think we have that work yet to do.”
Donahue, who is vice chair of the House Health Care Committee, said legislators also need to take a more active role in learning about and addressing the situation. “I think the Legislature has to dig deeper into the question of, why is this happening … and not just by anecdote and not just by hypothetical,” she said.
She added, however, that “as much as I’m trying to push the state to act, it shouldn’t be a state – meaning a public system – issue. It should be a health care system issue.”
Mike Faher discusses his reporting on the state’s mental health system in this week’s Deeper Dig podcast: