Federal regulators briefly threatened funding for the Brattleboro Retreat this July after an investigation found staff at the psychiatric and addiction treatment hospital left plastic trash bags accessible to residents who could use them for self-harm.
In one case in June, a patient who had previously attempted suicide was found trying to swallow part of a plastic bag at the Retreat, according to the investigation.
Officials also said that staff violated other regulations when they restrained patients without documenting permission from doctors, didn’t stop using physical restraints at the earliest possible opportunities and in one case, didn’t take safety precautions when holding down a patient.
On July 25, Vermont officials, acting on behalf of the Centers for Medicare and Medicaid (CMS), placed the hospital in “immediate jeopardy” status.
That status is given when regulators determine conditions in a facility present a likelihood of causing serious injury or harm to patients, and means that federal funding is at risk unless hospital staff take corrective action.
The investigation was prompted by a complaint to the Vermont Division of Licensing and Protection, which completed the July survey of the Retreat for the federal government.
The outcome of the investigation was first reported by Counterpoint, a publication of Vermont Psychiatric Survivors, a nonprofit that advocates for psychiatric patients.
Since the July investigation, the Retreat has implemented a “plan of correction” to realign with regulations.
Officials returned to the hospital during the first week of September and found that they were in total compliance with federal standards, according to Sarah Sherbrook, the acute care manager at the Division of Licensing and Protection.
But officials with the division initially placed the Retreat in “immediate jeopardy” because patients were able to access plastic trash bags.
On June 13, a patient who had been found at “moderate risk” for suicide and had made suicidal statements that day was found lying on the bathroom floor “with a portion of a plastic bag hanging from their mouth attempting to swallow the plastic,” according to the report completed by CMS in July.
An internal investigation determined that the patient had been able to obtain the plastic from the side of a locked trash barrel. When federal investigators arrived, they found inpatient units at the hospital had “locked trash barrels with excessive plastic bag exposure.”
“The potential for further patient self-harm on any of the other 6 patient care units was not identified or considered by hospital staff,” the report states.
Meghan Baston, the Retreat’s chief nursing officer, said staff had removed plastic from the unit where the June incident took place, but hadn’t removed it from other units.
After officials brought the violation to the attention of hospital staff, they immediately removed the plastic from the rest of the building, and the “jeopardy” status was lifted just hours after it was designated.
But over the course of their investigation, the federal officials uncovered other violations, many of which stemmed from the hospital’s use of physical restraints.
The investigators found that with two recent patients, hospital staff used physical restraint without a documented order from a doctor or licensed independent provider, as required under federal regulations.
Baston said staff never restrain patients without permission from doctors. In the cases cited by CMS, she said staff had obtained orders, but failed to document them.
“The issue was that order did not get entered into the medical records system. So when the surveyors come and look there’s no order there,” Baston said.
In one incident examined by regulators, staff used restraint on a patient with a shoulder injury without proper “safety interventions.”
The patient who had pushed a nurse and “reached out to assault” a mental health worker was restrained face down on a cement floor, according to the report. After being held down the patient required medication for shoulder pain.
One mental health worker who took part in the “take down” of the patient said they didn’t know the patient had a shoulder injury “or precautions to take” at the time of the incident.
Under federal regulations, restraints are only supposed to be used on patients for their or others’ immediate safety. The report said that in some cases, the Retreat failed to stop using restraints “at the earliest possible time.”
On June 24, a patient “incited a riot,” charging at a staff member who she injured and barricading herself in a hallway with a refrigerator from the kitchen, the report said. The patient refused medication, and was restrained in a restraint chair.
The patient remained in the chair for about two hours and received regular assessments from a nurse.
But CMS officials found and the nurse confirmed that his or her written assessments “did not contain sufficient reasons for the patient to remain in the restraint chair.”
Baston said that the Retreat has not improperly restrained patients. Its violations instead stemmed from poor documentation that did not explain why patients remained in restraint.
“I again as the chief nursing officer do not believe that the staff at this hospital are secluding or restraining patients longer than what is best for the patient,” Baston said.
“But it was not documented in a way that would tell that story,” she said.
In another incident detailed in the report, a “belligerent” and “uncooperative” patient who refused medication and threatened staff was placed in isolation for two hours.
Investigators found, and the nurse who was handling the patient confirmed that documentation of the incident “did not contain sufficient reasons for initiating and/or continuing seclusion” for the patient.
In the wake of the report, Sarah Squirrell, the commissioner of the Vermont Department of Mental Health said that the department will “continue to provide oversight” at the Retreat to make sure it remains in compliance with federal regulations.
“For any treatment provider at any time to have findings that would indicate that patient safety was at risk is of great concern to the department,” Squirrell said.
“Of course of particular concern for us is making sure that those who are at risk for suicide, that there are appropriate oversight, quality and therapeutic measures in place to ensure their safety,” she said.
In recent years, officials have found the Brattleboro Retreat in violation of several regulations.
In 2016, a patient killed himself within 24 hours of leaving the psychiatric facility. At the time, a state probe found staff members violated regulations when they failed to inform a guardian and a caseworker of the patient’s impending discharge, didn’t properly assess the patient’s discharge plan. The facility then changed its admission and discharge practices.
In 2013, CMS threatened to withhold federal funding because the Retreat wasn’t providing adequate care for patients.
Among its findings, CMS said staff routinely restrained and secluded patients without cause and, in one case, forcibly medicated a patient.
