The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SPRINGFIELD HOSPITAL PO BOX 2003 SPRINGFIELD, VT 05156 Feb. 4, 2014
VIOLATION: STAFFING AND STAFF RESPONSIBILITIES Tag No: C0970
Based on staff interview and record review, the Condition of Participation: Staffing and Staff Responsibilities was not met as evidenced by the failure of the Windham Center/ PPS Excluded Distinct Part Psychiatric Unit of Springfield Hospital to ensure sufficient staff coverage was available at all times to provide essential services and able to respond to emergent events or procedures and to be sufficient to meet the needs of all patients demonstrating psychosis or other behavioral symptoms.

Refer to C-0253
VIOLATION: SUFFICIENT STAFF Tag No: C0974
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and record review, the Windham Center/ PPS Excluded Distinct Part Psychiatric Unit of Springfield Hospital failed to ensure sufficient staff coverage was available at all times to provide essential services and able to respond to emergent events or procedures and to be sufficient to meet the needs of patients demonstrating psychosis or other behavioral symptoms for 2 applicable patients. (Patient #1, #2 ) Findings include:

1. Per record review Patient # 2 was admitted on [DATE] at approximately 2145 (9:45 PM). The patient was first seen and evaluated at the Dartmouth Hitchcock Hospital and cleared for medical purposes prior to being accepted at the Windham Center where the patient presented with psychotic features including auditory and visual hallucinations, disorganized behavior, and needing to be re-directed by staff for intrusive behavior toward other patients. The only nurse progress note written prior to the patient being transferred to the Springfield Hospital Emergency Department (ED) for evaluation was written by the Registered Nurse (RN) at 10:00 PM. The note details the patient as being disorganized, agitated, and tearful, and admitting to hearing voices. The nurse further states that the patient initially spit out a psychotropic medication to help sedate [him/her] and was placed on 15 minute observations for safety. The documentation on the 15 minute observation form details the patient from 9:15 PM until transfer to the ED as follows: "....with staff, whispering, resting, lying on floor, agitated and crying......". There is no documentation in the nurse's note regarding the patient being violent, threatening, or unmanageable. There is no documentation in the medical record that the patient required any emergency interventions prior to his/her transfer to the Springfield Hospital ED. There is a lack of documentation in the medical record to include both physician notes and nursing notes that Patient #2 (required) a second evaluation for possible medical reasons not discovered in the Dartmouth Hitchcock Medical Center evaluation.

Further review of the medical record discloses that the RN received a verbal order at 10:15 PM on 2/25/2013 to transfer Patient #2 to the Springfield ED. The physician order is accompanied by a physician discharge summary dictated on 3/5/2013 that states the nursing staff judged the patient to be too acute to remain on the unit, and was transferred to the emergency department for reevaluation, sedation if necessary, and disposition to a more appropriate facility.

2. Per record review, Patient #1, with a diagnosis of Schizoaffective disorder and PTSD, was admitted to the Windham Center/ PPS Excluded Distinct Part Psychiatric Unit of Springfield hospital on [DATE] as an involuntary admission. Prior to admission Patient #1 was involved in a assaultive incident on 12/6/13 at an outpatient mental health agency resulting in police intervention and subsequent injury to staff at the agency. The agency had been providing mental health services/case management over a 10 year period for Patient #1 without incident prior to the assault on 12/6/13. Patient #1 was brought to a local emergency department where the patient was screened for involuntary hospitalization . At the time of the incident on 12/6/13 Patient #1 confirmed s/he had not been compliant with taking prescribed psychotropic medications for 9 days. Per review of Emergency Department documentation, Patient #1 was compliant with medication and cooperative with staff and was provided security by the County sheriff's department.

After review by Windham Center Nurse Manager and psychiatrist of information provided and following their referral/intake process the Windham Center accepted Patient #1 for involuntary admission. Upon arrival on the evening of 12/10/13, Patient #1 was cooperative, accepted medication and interacted with staff. On 12/11/13, Patient #1 expressed concerns about his/her ability to control some sexual urges and informed staff s/he had difficulty controlling behaviors. Recreational Therapy provided Patient #1 art supplies which Patient #1 utilized effectively. Further deescalation was provided by staff during the afternoon of 12/11/13 and Patient #1 remained cooperative. Per "Patient Progress Note" at 16:21 on 12/11/13, the Nurse Manager documents Patient # 1 stated "... the danger has passed I'm OK, the medication and music helped". When consulted on 12/11/13 the Nurse Manager of a psychiatric unit where Patient #1 had previous hospitalization s, the Windham Center Nurse Manager was informed and documented that during Patient #1's previous hospitalization s "...they (other psychiatric unit) have never seen him/her touch anyone, despite his/her ranting and raving and telling people how scary s/he is, s/he has never actually touched a staff member or patient". During the night of 12/11/13 progress notes indicate Patient #1 was cooperative and for additional monitoring a security guard was assigned to the patient.

Per "Patient Progress Note" for 12/12/13 at 16:09, Patient #1 expressed to staff that s/he was "...having a difficult time" and "...reported having strong sexual thoughts...." about a staff member. The patient was redirected and agreed to stay in his/her room. Shortly after, Patient #1 requested to be transferred, voicing concerns about remaining in control of his/her behaviors. During this time, no additional therapeutic support was provided; attempts to stabilize were not evident; ongoing 1:1/2:1 was not offered; additional security staff was not scheduled, use of the seclusion/quiet room was not utilized, and the decision was made by Windham Center staff to transfer the patient to the Emergency Department (ED) at Springfield Hospital so County Sheriffs could provide security. Local police were requested and accompanied by a State Police officer and without consideration of Patient #1's personal dignity and Patient Rights, Patient #1 was removed from the Windham Center and although not charged with a criminal offense, was handcuffed and brought to the Bellows Falls Police Station at 16:45. While still considered a patient of the Windham Center but without any medical oversight by Windham Center staff, Patient #1 was detained for greater then 2 hours at the police station. From the police station, while still being considered a patient of the Windham Center, Patient #1 was then transferred to the Springfield Hospital ED and at 21:24 on 12/12/13.

Patient #1 remained in the ED for 8 days, continued to be considered a patient of the Windham Center, without the benefit of a therapeutic milieu of a psychiatric facility. While detained, Patient #1 was assigned to either a small exam room in the ED or the Ambulatory Care Unit monitored by County Sheriffs and/or security and a Mental Health Worker. It was not until 12/20/13, Patient #1 was transferred to another psychiatric unit.

Per Windham Center Inpatient Plan of Care last approved 6/13/13 states " The Windham Center accepts admission twenty-four hours a day and provides a comprehensive assessment, rapid crisis stabilization, medication management, and rapid return to community living."
However, per interview on 2/3/14 at 2:25 PM the Nurse Manager stated the Windham Center is able to manage non aggressive and medication compliant patients who are not violent, however they do accept 72 hour involuntary admissions. S/he also stated staff transfers patients to the ED for the administration of a intramuscular psychotropic emergency medication when a patient is refusing to take the medication orally at the Windham Center. The Nurse Manager justified transfers to the Springfield Hospital ED stating the staffing numbers (including RN's and Mental Health Workers) is insufficient to safely administer emergency medications, noting it was her/his opinion the procedure would require 6 staff members to assist with physically holding a patient to administer the prescribed drug. Per review of staffing schedules noted there was no more then 3-4 staff scheduled on each shift with days having the additional benefit of the Nurse Manager.

In addition, upon further discussion regarding staffing and unit safety, the Nurse Manger did confirm the Windham Center would follow the Springfield Hospital policy titled Workplace Violence last reviewed 5/10/12. This policy addresses how employees are to respond if there was a threat of violence involving a patient, visitor, current or former employee, or a stranger within the workplace. For the Windham Center, staff are to notify the switchboard to announce a "Code Orange". During the day, designated outpatient department employees located within the same building as the Windham Center would arrive on the unit to provide a show of support. However, when the outpatient offices are closed, calling a "Code Orange" would not facilitate extra staff. On the morning of 2/4/14 the Nurse Manager stated that during off hours given the present staff schedule, if an emergency situation did occur staff are to call 911, however the police station is 15 minutes away, hospital staff are located approximately 25 minutes away noting "...we are basically on our own". Furthermore noting 90% of staff are female at the Windham Center.
VIOLATION: COMPLIANCE FED, ST, AND LOCAL LAWS AND REGS Tag No: C0812
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and staff interview, the hospital failed to be In compliance with State of Vermont Statute Title 18, Chapter 42; Bill of Rights for Hospital Patients for 1 applicable patient. (Patient* 1). Findings Include;
1. Per State Statute 1862. Patients' Bill of Rights for Hospital Patients: "(1) The patient has the right to considerate and respectful care at all times and under all circumstances with recognition of his or her personal dignity.'
Per record review, Patient #1, with a diagnosis of Schizoaffective disorder and PTSD, was admitted to the Windham Center/ PPS Excluded Distinct Part Psychiatric Unit of Springfield hospital on [DATE] as an Involuntary admission. Prior to admission Patient #1 was Involved in a assaultive Incident on 12/6/13 at an outpatient mental health agency resulting in police Intervention and subsequent injury to staff at the agency. The agency had been providing mental health services/case management over a 10 year period for Patient #1 without Incident prior to the assault on 12/6/13. Patient was brought to a local emergency department where the patient was screened tor Involuntary hospitalization . At the time of the Incident on 12/6/13 Patient #1 confirmed s/he had not been compliant with taking prescribed psychotropic medications for 9 days. Per review of Emergency Department documentation, Patient #1 was compliant with medication and cooperative with staff and was provided security by the County sheriffs department,
After review by Windham Center Nurse Manager and psychiatrist of Information provided by a mental health agency and following their referral/Intake process the Windham Center accepted Patient #1 for Involuntary admission. Upon arrival on the evening of 12/10/13, Patient #1 was cooperative, accepted medication and interacted with staff. On 12/11/13, Patient #1 expressed concerns about his/her ability to control some sexual urges and Informed staff s/he had difficulty controlling behaviors. Recreational Therapy provided Patient #1 art supplies which Patient #1 utilized affectively. Further deescalation was provided by staff during the afternoon of 12/11/13 and Patient #1 remained cooperative. Per "Patient Progress Note" at 18:21 on 12/11/13, the Nurse Manager documents Patient # 1 stated"... the dangor has passed I'm OK, the medication and music helped". On 12/11/13 the Nurse Manager of a psychiatric unit where Patient #1 had past multiple admissions, waa consulted by the Windham Center Nurse Manager regarding Patient #1's previous behavioral presentation. The Windham Center Nurse Manager was informed and documented that during Patient #1's previous hospitalization s"...they (other pscychiatric unit) have never seen him/her touch anyone, despite his/her ranting adn raving and telling people how scary s/he is, s/he has never actually touched a staff member or patient". During the night of 12/11/13 progress notes indicated Patient #1 was cooperative adn for additional monitoring a security guard was assigned ot the patient.

Per "Patient Progress Note" for 12/12/13 at 18:08, Patient #1 expressed to staff that s/he was ",?having a difficult time" and "...reported having strong sexual thoughts...." about a staff member. The patient was redirected and agreed to stay In his/her room. Shortly after, Patient #1 requested to be transferred to another psychiatric facility, voicing concerne about remaining In control or his/her behaviors. During this time, no additional therapeutic support was provided; attempts to stabilize were not evident; ongoing 1:1/2:1 was not offered; additional staff was not scheduled, use of the seclusion/quiet room was not utilized, and the decision was made by Windham Center staff to transfer the patient to the Emergency Deportment (ED) at Springfield Hospital so County Sheriffs could provide security. Local police ware requested and accompanied by a state police officer and without consideration of Patient #1's personal dignity and Patient Rights, Patient #1 was removed from the Windham Center and although not charged with a criminal offense, was handcuffed and brought to the Bellows Falls Police Station at 16:45. While still considered a patient of the Windham Center without the benefit of medical oversight by Windham Center staff, Patient #1 was detained for greater than 2 hours at the police station. From the police station, while still being considered a patient of the Windham Center Patient #1 was then traneferrsd to the Springfield Hospital ED and at 21:24 on 12/12/13.
Patient #1 remained in the ED for 8 days, continued to be considered a patient of the Windham Center, without tha benefit of a therapeutic milieu of a psychiatric facility. While detained, Patient #1 was assigned to either a small exam room In the ED or the Ambulatory Care Unit monitored by County Sherlff and/or security and a Mental Health Worker, it was not until 12/20/13, Patient#1 was transferred to another psychiatric unit.
Per Interview during the morning of 2/4/13 both Ihe Medical Director for the Windham Center end the Director of Patient Care Services confirmed transfer/removal of Patient #1 by the police, handcuffed and detained at the police station while remaining a patient of the Windham Center, was not in compliance with with the State of Vermont Statute Title 18, Chapter 42 Bill of Rights for Hosptial Patients specifically the right to considerate and respectful care at all times and under all circumstances, with recognition of his or her personal dignity."
This Is a repeat violation
VIOLATION: RECORDS SYSTEM Tag No: C1116
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, Windham Center nursing staff failed to completely document pertinent information necessary during the monitoring of a patient who was identified to require further treatment in the Emergency Department. (Patient #2 ) Findings include:

1. Per record review Patient # 2 was admitted on [DATE] at approximately 2145 (9:45 PM). The patient was first seen and evaluated at the Dartmouth Hitchcock Hospital and cleared for medical purposes prior to being accepted at the Windham Center where the patient presented with psychotic features including auditory and visual hallucinations, disorganized behavior, and needing to be re-directed by staff for intrusive behavior toward other patients. The only nurse progress note written prior to the patient being transferred to the Springfield Hospital Emergency Department (ED) for evaluation was written by the Registered Nurse (RN) at 10:00 PM. The note details the patient as being disorganized, agitated, and tearful, and admitting to hearing voices. The nurse further states that the patient initially spit out a psychotropic medication to help sedate [him/her] and was placed on 15 minute observations for safety. The documentation on the 15 minute observation form details the patient from 9:15 PM until transfer to the ED as follows: "....with staff, whispering, resting, lying on floor, agitated and crying......". There is no documentation in the nurse's note regarding the patient being violent, threatening, or unmanageable. There is no documentation in the medical record that the patient required any emergency interventions prior to his/her transfer to the Springfield Hospital ED. There is a lack of documentation in the medical record to include both physician notes and nursing notes that Patient #2 (required) a second evaluation for possible medical reasons not discovered in the Dartmouth Hitchcock Hospital evaluation.
VIOLATION: QA - PERFORMANCE IMPROVEMENT Tag No: C0342
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and confirmed through staff interviews the facility failed to recognize opportunity for improvement and failed to address previously identified issues/concerns documented as adverse events. Findings include:

1. Per record review Patient # 2 was admitted on [DATE] at approximately 2145 (9:45 PM). The patient was first seen and evaluated at the Dartmouth Hitchcock Hospital and cleared for medical purposes prior to being accepted at the Windham Center where the patient presented with psychotic features including auditory and visual hallucinations, disorganized behavior, and needing to be re-directed by staff for intrusive behavior toward other patients. The patient was described in a nursing note as being agitated, and tearful, and admitting to hearing voices. When the patient was administered oral psychotropic medication s/he initially spit it out. Documentation on the 15 minute observation further details Patient #2 as: "....with staff, whispering, resting, lying on floor, agitated and crying......". Nurse's note did not identify the patient as being violent, threatening, or unmanageable. Within 2 hours of admission, nursing staff made the determination the patient required re-evaluation and possible administration by injection of an emergency psychotropic medication and requested the attending psychiatrist to order a transfer of the patient to the ED at Springfield Hospital where staff could assess the patient and medicate.

Per interview on 2/4/14 at 10:15 AM, the Medical Director for the Windham Center stated the unit has the medication and ability to administer intramuscular emergency involuntary medication, however during a previous interview on 2/3/14 at 2:25 PM the Nurse Manager stated there was lack of sufficient staff to handle the administration of an emergency involuntary injection. A Patient Safety Event had been completed at the time of Patient #2's transfer to the ED. Response by ED staff regarding the circumstances and necessity to re-examine Patient #2 had been in question, however the Medical Director acknowledged s/he was not aware of the circumstances nor had the case been reviewed to evaluate opportunities for improvement to ensure quality of care. Presently the Medical Director does not review any Patient Safety Events related to the Windham Center.

In addition, a review was conducted with the Medical Director regarding Patient #1, who was admitted on [DATE]. Within 2.5 days Patient #1 was escorted by police, while handcuffed, out of the unit and to the local police station without being charged with a criminal offense. Patient #1 remained at the police station, while still a patient of the Windham Center and was eventually transferred to the ED at Springfield Hospital. Both the Medical Director and Nurse Manager stated the unit has not been provided sufficient and complete information from referral sources and it has impacted the reliability of decisions made when accepting patients. Both Patients #1 and #2 were used as examples by the Medical Director and Nurse Manager to justify their concerns regarding the reliability of a specific referral source. However, there has been a failure to identify an opportunity to improve the present referral and intake process, criteria for acceptance, facilitate better communication between referring agencies and ensuring all information has been provided prior to accepting a patient for the Windham Center. The circumstances surrounding the transfer for both Patient #1 and #2 had not been reviewed or evaluated for Quality purposes to address potential remedial actions and further opportunity to improve patient care and services.

Refer to C-152 & C-0253

This is a repeat citation.