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.

CENTRAL VERMONT MEDICAL CENTER BOX 547 BARRE, VT 05641 July 6, 2012
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on staff interview and record review, the hospital failed to assure that 1 of 4 applicable patients restrained for emergency situations was treated in accordance with the hospital's policies/procedures regarding behavioral restraints. The patient' rights were violated when staff failed to discontinue the physical restraints at the earliest possible time and failed to obtain new orders for restraints after discontinuing restraints. (Patient #3) Findings include:

Per review of the medical record for Patient #3 on 7/5/12 and 7/6/12, the hospital failed to protect the rights of Patient #3 during the utilization of behavioral restraints, initiated for protection from self injurious and threatening behaviors during the period from 2215 hours on 1/14/12 until discontinuation of the restraints on 1/15/12 at 0800. Per review of the nursing documentation, there were no documented behaviors necessitating physical restraints after 2230 hours on 1/14/12. The patient was removed from 4 point locked restraints for toileting at 0000 - 0015 hours and then returned to 3 point locked restraints thereafter. The patient was released from the 3 point restraints for toileting at 0200 and returned to the restraints. Per the CON (Certificate of Need) flow sheets for Involuntary Treatment of the Violent/Assaultive Patient, commencing at 2215 on 1/14/12 and ending at 0800 on 1/15/12, nurses did not document any agitated behaviors after 2230 on 1/14/12. Nurses documented under the every hour assessment findings the following comments:
"2300, Per nursing supervisor........, keep pt. restrained for the night due to physical threats." (none described)
"1215 Pt. up to void in hat with 2 assist, cooperative - back in bed and compliant."
"0200 Pt up to void with 2 assist for unsteadiness and dizziness."
"0800 Off restraints - Took PO medications....accepted some care...to chair"
Other hourly documentation during the night stated "continues to need restraints" even though nurses documented behaviors as "cooperative, calm and asleep/awake" from 2230 until 0800 the following morning.
During interview on 7/5/12 at 12:45 PM, the Nurse Director of Critical Care stated that staff on the Critical Care Unit, including the physician provider, were not familiar with the hospital's 2 types of restraint policies/procedures, including different order sets for medical restraints and orders for behavioral restraints/seclusion. The orders for behavioral restraints were incorrectly implemented and documented.
Based on interviews throughout 7/5/12 and 7/6/12 with leadership staff from Quality and Risk Management, the Medical Affairs Director, the Vice President of Nursing and Quality, the Nurse Director of Critical Care and the Nurse Director of Inpatient Psychiatry and review of the hospitals written response to the patient grievance dated 4/12/12 and 5/30/12, the hospital concluded that the patient's right were violated regarding the use of restraints by failure to obtain restraint orders consistent with policy and regulatory requirements and failing to release from restraints at the earliest possible time, based on staff's assessments and documentation of behaviors from 1/14/12 to 1/15/12 at 0800.

(Refer also to A -168, A-169, A -171 and A-174).
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on staff interview and record review, the hospital failed to assure that staff complied with physician orders for physical restraint and hospital policy/procedures for behavioral restraints for 1 applicable patient in the sample. (Patient #3) Findings include:

Per record review on 7/5/12, Patient #3 was placed in physical restraints for behavioral reasons at 2315 hours on 1/14/12, and although staff removed the restraints at least 2 times to toilet the patient, staff re-applied the restraints each time until 0800 hours on 1/15/12, when a nurse documented that restraints were released. Nurses restrained the patient without physician orders after ending the orders when the patient was removed from restraints at 000 - 0015 hours and 0200 hours on 1/15/12. Per review of the hospital's policy titled "Restraint and Seclusion for Behavioral Health Patients, II A, #9 "If restraints or seclusion are discontinued prior to the expiration of the original order, a new order must be obtained prior to re-initiating restraint..". The failure to comply with the restraint policy by re-initiating restraints without a new order was confirmed during interview with the Vice President of Medical Affairs on 7/5/12 at 2:25 PM.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0169
Based on staff interview and record review, the hospital failed to assure that physician orders for use of behavioral restraint/seclusion were written in accordance with hospital policy and regulatory requirements for 1 of 4 applicable patients in the sample. (Patient #3). Findings include:

Per record review on 7/5/12 and confirmed by interview with the V.P. of Nursing and Quality, the RN Director of Inpatient Psychiatry and the Nursing Director of Critical Care Services on 7/6/12 at 1 PM, Patient #3's physician wrote orders on 1/14/12 noted at 1440 hours, stating "#3. If PT becomes a danger to herself or others, restrain as needed." Another physician telephone order written on 1/15/12 at 0330 stated "continue restraints, release if & when safe for patient....(restraints are 2 -4 pt depending on degree of agitation". During interview, the hospital staff confirmed that this physician had written orders that were not in accordance with the hospital's policies/procedures for Behavioral Restraint/Seclusion and were in violation of the patient's rights. The hospital's P/P stated under part II B, 8. "PRN orders for restraint or seclusion are prohibited".
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
Based on staff interview and record review, the hospital failed to assure that, for 2 of 4 patients in the applicable sample, orders for behavioral restraints were renewed every four hours for adults over 18 years of age, per hospital regulatory requirements regarding Patient Rights and per hospital policy for behavioral restraint use. (Patients # 1 & # 3). Findings include:


1. Per record review on 7/5/12 at 1:00 P.M., Patient #1 had a physician's order dated 1/2/12 for four point locked restraints written at 8:00 P.M. due to 'dangerous behavioral issues....assaultive behavior...auditory and visual hallucinations.. acting out.. yelling,' . Per record review, Patient #1 was restrained for 15 1/2 hours. There was no evidence in the clinical record of a subsequent physician order to continue the restraint every 4 hours as required by regulation and facility policy entitled "Restraint and Seclusion for Behavioral Health Patients", II, Section B, 4 a. This was confirmed during interview with the Nurse Director of Critical Care Services on 7/6/12 at 8:40 A.M..

2. Per record review and confirmed by interview with the Nurse Director of Critical Care Services on 7/5/12 at 12:45 PM and the Physician Vice President of Medical Affairs at 2:35 PM the same day, staff restrained Patient #3 for longer than 4 hours (from 1/14/12 at 2215 until 1/15/12 at 0800) and failed to renew the orders very 4 hours as required by hospital regulations and the hospital's policy as stated in example number 1 above. Nurses obtained a telephone order at 0330 on 1/15/12 to "continue restraints, release if and when safe for pt. , 1:1 obs. to continue (restraints are 2-4 point depending on degree of agitation).
Refer also to A- 154.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
Based on staff interview and record review, nurses failed to discontinue at the earliest possible time, 3 point locked physical restraints used for 1 of 4 applicable patients in the sample. (Patient #3) Findings include:

Per record review on 7/5/12, Patient #3 was documented as being restrained in 3 - 4 point locked restraints from 2215 hours on 1/14/12 until 0800 hours on 1/15/12.
Per the CON (Certificate of Need) flow sheets for Involuntary Treatment of the Violent/Assaultive Patient, commencing at 2215 on 1/14/12 and ending at 0800 on 1/15/12, nurses did not document any agitated behaviors after 2230 on 1/14/12. Nurses documented under the every hour assessment findings the following comments:
"2300, Per nursing supervisor........, keep pt. restrained for the night due to physical threats."
"1215 Pt. up to void in hat with 2 assist, cooperative - back in bed and compliant."
"0200 Pt up to void with 2 assist for unsteadiness and dizziness."
"0800 Off restraints - Took PO medications....accepted some care...to chair"

Other hourly documentation during the night stated "continues to need restraints" even though nurses documented behaviors as "cooperative, calm and asleep/awake" from 2230 until 0800 the following morning.

Per review of the hospital's policy "Restraint and Seclusion for the Behavioral Health Patient", page 6, #9 and #10 a., a RN will assess the patient's clinical status and then collaborate with the treatment team to determine the patient's readiness for tapering and release of the restraints. During interview on the afternoon of 7/5/12, the Nurse Director of Critical Care Services confirmed that nurses continued to maintain the restraints even though there was no evidence of the continued need or a reassessment of the patient's status.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on staff interview and record review, the facility failed to assure 2 of 4 applicable patients in the sample who were restrained for behavioral reasons were assessed by a physician or other LIP (licensed independent practitioner) as required by hospital policy/procedures. (Patients#1 & #3). Findings include:

1. Per record review on 7/5/12 at 1:00 P.M., Patient #1 was placed in 4 point locked restraints per a physician's order dated 1/2/12, 8:00 PM, due to dangerous behaviors including 'assaultive behavior with auditory and visual hallucinations' 'acting out, yelling', Per record review, Patient #1 was restrained for 15 1/2 hours. There is no evidence in the clinical record that Patient #1 had an initial face to face physician assessment within one hour or a subsequent assessment after 8 hours as required by a facility policy entitled "Restraint and Seclusion for Behavioral Health Patients", section B,2. This was confirmed during interview with the Nurse Director of Critical Care Services on 7/6/12 at 8:40 AM.

2. Per record review on 7/5/12, Patient #3 was restrained (and re-restrained after toileting)during the period from 2315 hours on 1/14/12 until 0800 on 1/15/12. Per review of the physician orders, the physician incorrectly wrote initial orders under "Physician Reassessment" at 11:38 PM on 1/14/12. At that time, the physician failed to describe the clinical condition of the patient including behaviors, thought process and affect/mood that required involuntary treatment. Additionally, there was no evidence of a face to face assessment every 8 hours for adults over 18 years of age, per the hospital's policy, (as referred to in example #1 above). The record stated that the physician saw the patient at 0830 hours on 1/15/12. The lack of required physician/LIP face to face assessment was confirmed during interview with the Nurse Director of Critical Care Services on 7/6/12 at 1 PM.