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Based on staff interviews and record reviews conducted on days of the on-site complaint survey, from 2/5/19 through 2/7/19 the Condition of Participation: Patient Rights was not met as evidenced by the hospital's failure to provide sufficient interventions to assure each patient's rights are protected.

Refer to:
A - 0144: Failure to assure that each patient's rights to receive care in a safe setting.

A - 0154: Failure to assure patients' rights by relinquishing patient care to law enforcement.

A - 0179: Failure to perform 1:1 face to face assessment after the application of restraints.

Based on observations, interviews and record reviews the hospital failed to ensure each patient's rights to receive care in a safe environment was maintained during the provision of services in the Emergency Department (ED) for a patient placed in handcuffs and prone position; the presence of ligature risks in a designated bathroom and not ensuring a patient's assigned ED room was safely maintained. (Patient #10) Findings include:

1. Patient #10 was brought to the ED by police on 10/3/18 after demonstrating psychotic, assaultive and self harm behaviors in the community. Prior to arrival in the ED Patient #10 had been handcuffed by the police with arms placed behind the patient's back. A Nursing Progress note states on 10/3/18 at 14:56 the patient had been placed on a stretcher in room 10 "....currently lying prone (face down)...in handcuffs behind his/her back", creating a risk factor and vulnerability for positional asphyxia. Per the Journal of Psychiatric and Mental Health Nursing/Volume 23, Issue 3-4 published 3/28/16 states: " Although the use of prone restraint should be avoided....when used as a last resort, concerns remain about the ability of staff to maintain dignity, welfare and safety of the patient and minimize the potential adverse outcomes associated with restraint....restraint-related deaths are multifactorial with prone restraint remaining a concern due to physiological and psychological risks". Per interview on 2/7/19 at 2:45 PM, Nurse #1 confirmed Patient #10 remained in handcuffs and liked being prone on the stretcher because the patient stated s/he was "scuba diving" although at the time Patient #10 was experiencing acute psychosis and was described per "Application for Emergency Examination a Mental Status Examination" dated 10/3/19: "S/he has no insight into his/her condition and poor judgement". By 15:25 the handcuffs were removed from behind the patient's back by the police however, one arm was then handcuffed to the stretcher which were removed eventually removed at 16:05. In addition, per hospital policy Violent Patient Management: Restraint/Seclusion (last reviewed 1/9/2019) states: " Section IV E. Application of Restraints c. Mechanical Restraints shall not be used when the patient is in a prone position."

2. During a tour of the ED on 2/7/19 at 2:30 PM accompanied by the Chief Nursing Officer (CNO) and the Director of Quality, Utilization & Care Management a bathroom, identified to be used specifically for vulnerable patients with psychiatric diagnosis, a safety risk existed associated with the following observations: 3 grab bars located beside and behind the toilet creating a ligature risk due the opening on the grab bars creating a potential for looping or attaching a cord or other material for the purpose of strangulation. A container used for the disposal of feminine hygiene products situated beside the toilet was observed to have sharp edges on the cover, creating the potential for patient self-harm. It was also confirmed, not all patients are observed during the use of the bathroom. The safety concerns were confirmed at the time of observation by the CNO and Director of Quality, Utilization & Care Management.

3. Per ED Nursing Progress Note on 10/5/18 at 08:33, although on 1:1 observation by contracted security officer, Patient #10 "...displays some strange behaviors. Standing on a chair reaching up into ceiling tiles". Per interview with CNO and Director of Quality, Utilization & Care Management confirmed a chair should not have been left in this patient's room due to the furniture being used as a projectile object creating a risk of harm to staff or other individuals within the ED. They further confirmed ED staff frequently conduct room safety checks, especially during change of shifts which would have included the removal of all items that can be picked up and thrown to include chairs. In addition, Patient #10 was at risk for injury resulting from a potential fall while standing on the chair that had been left in the patient's room.

Based on staff interview and record review, the hospital failed to protect a patient's rights when a patient was subdued by a sheriff and with the assistance of contracted security staff was immobilized, handcuffed and while on the floor in a kneeling position, the patient was administered Emergency Involuntary Medication by ED staff for 1 of 2 applicable patients. (Patient #2). The hospital also failed to ensure two patients (Patient #9 and Patient #10) were free from unnecessary restraints (handcuffs) applied by law enforcement. Findings include:

1. On 12/17/18 at 12:56 Patient #2 was brought to the ED by the State Police after demonstrating threatening behavior to family and attempting to set fire to a building where s/he believed demons resided. Patient #2 presented to the ED with acute Schizo-affective disorder and psychosis and a recent history of medication non-compliance. The patient was evaluated and deemed to meet criteria for involuntary psychiatric hospitalization. While awaiting a psychiatric hospital bed, Patient #2 remained detained in the ED. During the afternoon of 12/17/18, Patient #2 was subsequently assigned a sheriff who is contracted through the Department of Mental Health (DMH) to provide supervision because Patient #2 was now in temporary custody of the Commissioner of Mental Health under an emergency examination application. On 12/17/18 at 16:35 a Nursing Progress Note states Patient #2 begins yelling and questioning why s/he was not being taken to jail or a psychiatric hospital. Patient #2 attempted to leave assigned room #6 and upon contact with the Sheriff, who was stationed outside the patient's room, pushes the sheriff in the chest. The sheriff pushed Patient #2 back into room 6; Patient #2 ends up on the floor face down. Two hospital contracted security officers who were providing 1:1 for two other ED patients came to the sheriff's assistance, although the sheriff did not request assistance. Patient #2's shoulders/arms were held by the contracted security guards enabling the sheriff to apply handcuffs behind the patient's back. While still handcuffed and in a kneeling position on the floor, ED staff administered Involuntary Emergency Medications by intramuscular (IM) injection to include Benadryl 50 mg; Haldol (antipsychotic) 5 mg; and Ativan (anti-anxiety) 2 mg. Shortly after, the patient was placed back on the ED stretcher in room 6 and remained handcuffed for approximately 30 minutes and once calm, the handcuffs were removed. Staff did request the removal of the handcuffs, however the sheriff would not consider removal of the handcuffs until the patient was calm. No other assessment for alternative restraints were considered or further staff interaction with hospital supervisor or management to have the handcuffs removed.

Per hospital policy and procedure Violent Patient Management: Restraint /Seclusion last reviewed 1/9/19 Section IV Procedure E. "Application of Restraint f. At NO time may law enforcement be called to assist in a "take down", "therapeutic hold" "staff assists" or administering Emergency Involuntary Medication of the hospital's patient. and "g. Sheriff officials assigned by the Vermont Department of Mental Health for the watch of involuntary patients take direction from the clinical team and are not in a law enforcement capacity. Sheriff Officers cannot be asked to provide behavioral management or care that is otherwise the responsibility of the hospital staff and provider." Although staff had requested the removal of the handcuffs, the concerns regarding the use and discontinuation of the handcuffs specifically as a behavioral restraint was not pursued by ED providers and/or management, despite the fact Patient #2 was not under arrest or being charged criminally. In addition, per hospital Orientation & Education Guide for Law Enforcement/Forensic/Custodial Officer/Agent states in " Section 4: Management of a Patient in Custody: 1. The use of handcuffs, manacles, shackles, other chain-type devices, or other restrictive devices may only be applied by non-hospital employed, or contracted law enforcement officials for custody, detention and public safety reasons. b. Hospital and contracted employees are NOT allowed to use such devices. 2. The sheriff is not acting as a law enforcement officer while providing a patient watch." The event associated with the sheriff and Patient #2 was confirmed by the ED nurse manager on 2/5/19 at 3:30 PM. In addition, per telephone interviews during the morning of 2/7/19, both contracted security officers confirmed they had assisted the sheriff by securing the arms/shoulders of Patient #2 to facilitate the application of handcuffs. Once the patient was handcuffed both security officers stated they returned to their assigned stations.

2. Per review of a physician's progress note dated 1/13/19, Patient #9 "arrived with police physically restrained and screaming incessantly". S/he was deaf, had a history of mental health problems, and was under the influence of alcohol. Per review of a nursing progress note from 1/13/19 at 10:30 PM, "pt was admitted to ED by ambulance ....Pt was screaming , kicking, spitting, hitting, and biting while on Rescue's stretcher in hand cuffs and secured to stretcher ... .....Multiple attempts were made to communicate with pt but" s/he "would close" his/her "eyes, yelling obscenities and making vulgar gestures ... ...Pt was moved to ED stretcher with 3 CPI (Crisis Prevention Institute) trained ED staff and 2 MT's (Emergency Medical Technician's), request to remove hand cuffs denied by police. Involuntary medications Haldol (antipsychotic medication) 5 mg (milligrams), Ativan (anti-anxiety medication) 2 mg and Benadryl 5 mg adm IM (intramuscular)". At 10:45 PM, "Pt cont to be an immediate threat to staff and self as evidenced by violent behavior. 4 point restraints were applied". Per interview on 2/7/19 at 3:02 PM with an ED Registered Nurse (RN), s/he stated that the Patient #9 was given Emergency Involuntary Medications (EIM) while restrained in handcuffs. Per interview with the ED Nurse Manager at that time, s/he confirmed that handcuffs were not an appropriate form of a restraint and that hospital staff does not apply them.

3. Patient #10, diagnosed with Bipolar disorder and experiencing a manic episode and psychosis was brought to the ED by police on 10/3/18 after demonstrating psychotic, assaultive and self harm behaviors in the community. Prior to arrival to the ED Patient #10 had been handcuffed by the Brattleboro police with arms placed behind the patient's back. Upon arrival to the ED at approximately 14:35 patient remained handcuffed and was placed in Room 10. ED physician progress note on 10/3/18 at 1600 states attempts to de-escalate Patient #10 had been effective, law enforcement presence seems to make him/her agitated again very quickly. The ED physician further states: "At this point, we are going to ask law enforcement to remove the handcuffs and determine if (Patient #10) can remain safe without physical restraint". Initially, the handcuffs were removed by the police from one hand, and police handcuffed Patient #10 to the stretcher in Room 10 where the patient was held. At 16:05 the handcuffs were removed and Patient #10 was then placed in 2 point hospital wrist restraints. Per the Orientation & Education Guide for Law Enforcement/Forensic/Custodial Officer/Agent states in Section 4: "Management of a Patient in Custody" the use of handcuffs or other restrictive devices "...are not acceptable for use on a patient who is not in the custody or direct supervision of the police". Patient #10 was not in custody or under arrest of law enforcement, but was identified as an individual in need of psychiatric care and hospitalization. Law enforcement devices such as handcuffs are not considered a safe an appropriate health care restraint intervention. Per interview on 2/7/19 at 1:20 PM, the nurse assigned to Patient #10 on 10/3/18 at 1500 confirmed the continued use of the handcuffs for approximately 1 hour and 30 minutes until they were removed at approximately 16:05 by law enforcement. The prolonged use of the handcuffs after arrival in the ED was a breach of the patient's rights to include considerate and respectful care.

Based on interview and record review the hospital failed to show evidence that a physician, licensed independent provider (LIP), and/or trained registered nurse (RN), conducted a one hour face to face assessment after the initiation of physical and/or chemical restraints for 2 of 10 applicable patients (Patient #9 and Patient #11). Findings include:

1. Per review of a nursing progress note for Patient #9 from 1/13/19 at 10:30 PM, "pt was admitted to ED by ambulance ....Pt was screaming , kicking, spitting, hitting, and biting while on Rescue's stretcher in hand cuffs and secured to stretcher ... .....Multiple attempts were made to communicate with pt but" s/he "would close" his/her "eyes, yelling obscenities and making vulgar gestures ... ...Pt was moved to ED stretcher with 3 CPI (Crisis Prevention Institute) trained ED staff and 2 EMT's (Emergency Medical Technician's), request to remove hand cuffs denied by police. Involuntary medications Haldol (antipsychotic medication) 5 mg (milligrams), Ativan (anti-anxiety medication) 2 mg and Benadryl 5 mg adm IM (intramuscular)". At 10:45, "Pt cont to be an immediate threat to staff and self as evidenced by violent behavior. 4 point restraints were applied". There was no evidence in the medical record that a one hour face to face assessment was done by a physician, LIP, and/or RN after the initiation of physical and/or chemical restraints for Patient #9. Per interview on 2/7/19 at 10:36 AM with the ED Nurse Manager, s/he confirmed that there was no face to face assessment completed by a physician, LIP, and/or RN after the initiation of physical and chemical restraints for Patient #9.

2. Per review of a physician's progress note for Patient #11 from 1/4/19, the patient was a teenager with a medical history of autism who presented to the ED at approximately 9:00 AM after assaulting a family member on the way to school. S/he had arrived to the ED with the police and was aggressive and spitting. Per a nursing progress note for Patient #11 from 1/4/19 at 12:52 PM, "At approximately 11:50 the patient began escalating. Swatting at Security, threatening to shoot them, hit this writer multiple times. Attempted both verbal descalation and verbal redirection, both failed. Patient offered PO (by mouth) and IM (intramuscular) medication, which" s/he "declined. EIM (Emergency Involuntary Medication) ordered, but seclusion used instead ....At 12:40 the patient was able to follow directions, showed a calm demeanor and accepted PO medication. Seclusion removed at 12:40". There was no evidence in the medical record that a one hour face to face assessment was done by a physician, LIP, and/or RN after the initiation of seclusion for Patient #11. Per interview on 2/7/19 at 10:51 AM with the ED Nurse Manager, s/he confirmed that that there was no face to face assessment completed by a physician, LIP, and/or RN after the initiation of seclusion for Patient #11.

Based on staff interview and record review, the hospital failed to ensure that Quality Improvement activities identified and focused on high-risk and problem prone areas including the use of handcuffs within the Emergency Department. Findings include:

On 3 separate occasions the inappropriate and/or prolonged use of handcuffs was noted to have occurred during the provision of care in the ED. The first incident occurred on 12/17/18 when Patient #2, diagnosed with acute Schizo-affective disorder and psychosis and a recent history of medication non-compliance begins yelling and questioning why s/he was not being taken to jail or a psychiatric hospital. Patient #2 attempted to leave assigned room #6 and approaches and pushes a sheriff in the chest. The sheriff, assigned by DMH to provide supervision of Patient #2, was stationed outside room #6. The sheriff pushed Patient #2 back into Room 6; Patient #2 ends up on the floor face down. Two hospital contracted security officers who were providing 1:1 for 2 other ED patients came to the sheriff's assistance, although the sheriff did not request assistance. Patient #2's shoulders/arms were held by the contracted security guards enabling the sheriff to apply handcuffs behind the patient's back. While still handcuffed and in a kneeling position on the floor, ED staff administered Involuntary Emergency Medications by intramuscular (IM) injection to include Benadryl 50 mg; Haldol (antipsychotic) 5 mg; and Ativan (anti-anxiety) 2 mg. Shortly after, the patient was placed back on ED stretcher and remained handcuffed for approximately 30 minutes and once calm, the handcuffs were removed. Staff did request the removal of the handcuffs, however the sheriff would not consider removal of the handcuffs until the patient was calm. No other assessment for alternative restraints were considered.

A second incident involved Patient #10, diagnosed with Bipolar disorder and experiencing a manic episode and psychosis was brought to the ED by police on 10/3/18 after demonstrating psychotic, assaultive and self harm behaviors in the community. Prior to arrival to the ED Patient #10 had been handcuffed by the Brattleboro police with arms placed behind the patient's back. Upon arrival to the ED at approximately 14:35 patient remained handcuffed and was placed in Room 10. Patient #10 remained handcuffed for 90 minutes, when the police removed the handcuffs and the patient was then placed in 2 point wrist restraints.

A third incident involved Patient #9 who was admitted to the ED via ambulance. "Pt was screaming, kicking, spitting, hitting, and biting while on Rescue's stretcher in hand cuffs and secured to stretcher ... .....Multiple attempts were made to communicate with pt but" s/he "would close" his/her "eyes, yelling obscenities and making vulgar gestures ... ...Pt was moved to ED stretcher with 3 CPI (Crisis Prevention Institute) trained ED staff and 2 EMT's (Emergency Medical Technician's), request to remove hand cuffs denied by police. Involuntary medications Haldol (antipsychotic medication) 5 mg (milligrams), Ativan (anti-anxiety medication) 2 mg and Benadryl 5 mg adm IM (intramuscular)". Per interview on 2/7/19 at 3:02 PM with ED Registered Nurse (RN), s/he stated that the Patient #9 was given Emergency Involuntary Medications (EIM) while restrained in handcuffs.

Each of these incidents involving the use of handcuffs reflected the failure of ED staff and contracted security officers to protect the rights of each patient. Both Quality Assessment/Performance Improvement (QA/PI) and hospital leadership failed to analyze and implement a plan to ensure the inappropriate use of handcuffs was not continuing. Although ED nursing staff had reportedly requested law enforcement to have handcuffs removed during each incident, retrospectively there was an absence of direction and communication with law enforcement within the community in an attempt to reduce the use of handcuffs specifically with patients who are presenting to the ED with behavioral health symptoms and are not under arrest. Advocating for the safety and rights of each patient when restrained with handcuffs within the ED was limited and QA/PI failed to capture the high-risk concerns associated with the incidents.
Per interview on 2/5/19 at 3:15 PM the Director of Quality, Utilization & Care Management, the ED Director and Nurse Manager confirmed reviews of restraint/seclusion use in the ED is being conducted, however the specifics associated with law enforcement and handcuffs has not been effectively evaluated and opportunities for improvement have not been identified.

Based on staff interview and record review, the hospital's Quality Assurance/Performance Improvement (QA/PI) failed to effectively analyze and evaluate the failure to discontinue the use of handcuffs by law enforcement in the ED; and there was a failure of QA/PI to identify additional opportunities for improvement. Findings include:

Per hospital policy Incident Reporting - Patient/Visitor/Employee last reviewed on 9 /2018 states regarding "V. Responsibilities A. Employees: Staff are encouraged and expected to complete an electronic Incident Report (Quantros) when events occur that impact patient care, management and treatment.....The report should be made as soon as possible within 24 hours to allow for investigation." However, ED staff including nurses and managers involved with an incident associated with a Sheriff and Patient #2 on 12/17/18 failed to file a report. Despite the fact a significant incident had resulted when Patient #2 had an altercation with a Sheriff assigned by DMH that resulted in Patient #2 laying on the floor, hand cuffed behind his/her back by the Sheriff with the assistance of contracted security guards and was administered Involuntary Emergency Medications while handcuffed. The incident demonstrated a lack of clarification of roles to include both the Sheriff's function, use of handcuffs as a restraint and the interactions of 2 security guards at the time of the incident.

Per interview on 2/5/19 at 3:15 PM, the Director of Quality, Utilization & Care Management confirmed staff failed to file an incident report related to the events that occurred on 12/17/18 involving Patient #2. Although QA/PI, ED Director and Nurse Manager review restraint/seclusion use in the ED, the specifics associated with law enforcement and handcuff use has not generated an opportunity to investigate the situation, evaluate the significant chain of events of 12/17/18 or collaborate with law enforcement regarding their role in the ED specifically associated with the management of patients with behavioral/psychiatric symptoms. Presently there is no preventative measures to eliminate the use of handcuffs by law enforcement for those individuals who are not charged with a crime, not in police custody or identified as a prisoner who would be removed and incarcerated.

Based on interview and record review the hospital failed to ensure medical records were complete, dated, timed, and authenticated by the person(s) responsible for providing and/or evaluating services for 1 of 11 applicable patients (Patient #9). Findings include:

Per review of a nursing progress note for Patient #9 from 1/13/19 at 10:30 PM, "pt was admitted to ED by ambulance ....Pt was screaming , kicking, spitting, hitting, and biting while on Rescue's stretcher in hand cuffs and secured to stretcher ... .....Multiple attempts were made to communicate with pt but" s/he "would close" his/her "eyes, yelling obscenities and making vulgar gestures ... ...Pt was moved to ED stretcher with 3 CPI (Crisis Prevention Institute) trained ED staff and 2 EMT's (Emergency Medical Technician's), request to remove hand cuffs denied by police. A physician's order from 1/13/19 for Emergency Involuntary Medications read, "5 mg Haldol, 2mg Ativan, 50 mg Benadryl". Per review of the Medication Administration Record (MAR) from 1/13/19, there was no evidence that the 50 mg of Benadryl was given to Patient #9. Per interview on 2/7/19 at 10:26 AM with the ED Nurse Manager, s/he confirmed that there was nothing recorded on the MAR to indicate that the Benadryl was given to Patient #9.