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.

UNIVERSITY OF VERMONT MEDICAL CENTER 111 COLCHESTER AVE BURLINGTON, VT 05401 April 3, 2013
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure staff, identified as mandated reporters, who became aware of an allegation of abuse made by a child, reported the allegation to Child Welfare Services, as required. (Patient #1) Findings include:

Per interview on 4/3/13 at 3:12 PM, the Director of Social Services stated "....our practice/our policy is that everyone should be on the look out for concerns related to abuse whether children or adults". The Director further stated Social Service staff are available 24/7 to assist staff or convince staff they may want to report allegations directly. However, on 11/7/12 when Patient #1, [AGE], arrived in PACU to recover from an endoscopic procedure and alleged s/he had been abused by staff from a State juvenile detention center, nursing staff failed to report as required. Patient #1 had a past history of self injurious behaviors and was brought to the ED after ingesting an unknown foreign object. Upon presentation to the ED, s/he arrived in shackles and handcuffs in the custody of staff from the juvenile rehabilitation center.

Shortly after Patient #1's PACU admission, staff from the juvenile rehabilitation center, who had accompanied Patient #1 since admission to the hospital, requested to see the patient with the intent of reapplying handcuffs on Patient #1. Per interview on 4/2/13 at 2:00 PM PACU Nurse #1 stated Patient #1 began to cry and complained s/he did not want to return to the juvenile rehabilitation center. The PACU nurse stated s/he objected to having Patient #1 handcuffed stating the patient was being "...good". S/he was informed by one of the staff from the juvenile rehabilitation center it was "protocol". During the process of handcuffing the patient and a later episode when the handcuffs were moved, Patient #1 reacted violently when a staff member from the juvenile rehabilitation center approached or attempted to place hands on the patient. PACU Nurse #1 stated the patient was yelling "...get away from me, s/he hurt me..." and further alleging staff had hurt her/him at the juvenile rehabilitation center.

On 4/2/13 at 10:43 AM , when asked if there was any consideration by herself/himself to report allegations of physical abuse to Child Welfare Services, the PACU Nurse Manager stated "we didn't feel we needed to report". Although s/he is a mandated reporter, the Nurse Manager's justification was other staff were also aware of Patient #1's allegations. In regards to this patient, the Director of Social Services further acknowledged a report should have been made by the PACU staff to the Department of Children's and Families.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to assure care was provided in a safe setting during the provision and management of care for a prisoner patient. (Patient #1) Findings include:

The potential for an unsafe environment for patients recovering from anesthesia and surgical procedures was evident due to the hospital's failure to assure Security policy and procedures were followed.
On 11/7/12, Security Staff failed to adhere to Policy "Sec /Prisoner Patient" last updated 3/11/11 which states hospital staff or outside police departments or correctional facilities are to notify the Security Shift supervisor whenever a prisoner is brought to the hospital for inpatient or outpatient treatment. Upon notification, the prisoner patient's level of security would be determined, assessing the level of restraints being used. Communication would be made to other Security officers, alerting them of any special precautions. The policy further states: "If a correction officer, private security officer, or other law enforcement official will be supervising or sitting with the inmate, the Security shift supervisor will issue him/her a Security radio and inservice him/her on their radio call number, and the information sheet...".

Per review on 4/3/13, Patient #1, [AGE], was brought to the Emergency Department (ED) on 11/7/12 at 1242 after ingesting a foreign body with complaints of mid to esophageal and upper epigastric discomfort. The patient had a past history of self injurious behaviors with previous ingestion of foreign objects including pencils and a toothbrush. Patient #1 arrived wearing leg shackles and handcuffs and was accompanied by staff from a State juvenile rehabilitation center (a center used for short-term detention for youths and also operates a secure treatment program for youths). ED note written by EMT states at 12:42 "Coming from XXXXX for vomiting blood after swallowing object. Hx. of same. Will be in handcuffs and restrained. ED security aware".

As a result of the medical screening exam conducted in the ED for Patient #1, a consult was requested and completed by a pediatric gastroenterologist. It was determined Patient #1 required an emergent endoscopy procedure for the possible removal of plastic in Patient #1's stomach. At 14:49 Patient #1 was brought to Endoscopy where shortly after a Esophagogastroduodenoscopy (EGD) was performed. Patient #1 was then transferred to Post Anesthesia Care Unit (PACU) arriving at approximately 1555 with only leg shackles and no handcuffs. Although ED Security staff were aware of Patient #1, there was a failure to notify the Security shift supervisor of Patient #1's arrival and circumstance as per policy. As a result, hospital wide Security staff were not made aware of Patient #1's presence within the hospital nor had Security been given the opportunity to assess the safety needs for Patient #1 or the safety concern for other patients who may be receiving care and services within the vicinity of Patient #1. There was no documented evidence of communication between staff from the juvenile rehabilitation center who accompanied Patient #1 and hospital staff to determine their authority, the degree of Patient #1's elopement risk or the severity of the patient's behaviors.

Per interview on 4/2/13 at 2:01 PM, PACU Nurse #1 assigned to provide care to Patient #1 after the EGD on 11/7/12 stated s/he received only a brief notice from Endoscopy staff regarding the patient's previous history of ingestion and behavioral circumstances prior to Patient #1's admission to PACU. The nurse stated s/he attempted to strip "bay" area #49 in the PACU unit of dangerous material and/or equipment leaving what was needed to monitor the patient for post anesthesia recovery. Shortly after Patient #1's PACU admission, staff from the juvenile rehabilitation center, who had accompanied Patient #1 since admission to the hospital, requested to see the patient with the intent of reapplying handcuffs on Patient #1. PACU Nurse #1 stated Patient #1 began to cry and complained s/he did not want to return to the juvenile rehabilitation center. The nurse stated s/he objected to having Patient #1 handcuffed stating the patient was being "...good". S/he was informed by one of the staff from the juvenile rehabilitation center it was "protocol", however the PACU nurse further stated "I did not know where I stood wanting to be sure my patients were safe". However, hospital policy Sec states "The correctional facility or law enforcement agency sitting with the patient may determine the level of restraint and type of restraint necessary to restrain the patient". Upon application of the handcuffs by juvenile rehabilitation center staff, Patient #1 became immediately aggressive, yelling and screaming at staff, specifically the staff member who had applied the handcuffs. Patient #1 proceeded to roll on his/her side and began attempting to eat a plastic allergy wrist bracelet applied earlier in the day by hospital staff. PACU Nurse #1 stated a Code 8 was called (requesting assistance from the hospital's Security Officers and other support services). At 1600 a show of support arrived and staff was able to remove the plastic bracelet from Patient #1's mouth. Patient #1 continued kicking and screaming while in the leg shackles resulting in an injury to one of the Security Officers.

As a result of this incident it was determined by staff from the juvenile rehabilitation center to remove the handcuffs and reapply them behind Patient #1's back. Due to Patient #1's agitated behavior whenever staff from the rehabilitation center approached Patient #1, they requested the hospital security officers unclasp and remove the left handcuff and reapply it behind Patient #1's back. The Security officers complied. Hospital staff eventually were able to calm the patient and a Crisis Screener from First Call came and stayed with Patient #1. The decision was made to have the Sheriff's Department transport Patient #1 back to the juvenile rehabilitation center due to Patient #1's violent and dangerous behaviors accelerating whenever staff from the juvenile rehabilitation center approached the patient and the patient's refusal to be returned to the juvenile facility.

During the process for arranging Patient #1's discharge there was a failure to assure patient safety when both the PACU Nurse #1 briefly left Patient #1 alone at the bedside and Security Officer #1 also then left Patient #1 when notified by radio and told by the Security office to find members of the Sheriff's Department who had arrived to transport the patient back to the juvenile rehabilitation center. Per PACU Nurse #1 "I came back and s/he (Patient #1) was on the floor beating his/her head (on the floor)......I don't remember specifically asking how s/he got to the floor." The nurse stated s/he straddled the patient and attempted to prevent Patient #1 from hitting her head on the floor. A second Code 8 was called, resulting again with additional Security Officers responding. Eventually, staff from the Sheriff's Department and hospital Security Officers were able to get Patient #1 into a wheelchair, additional restraints were applied and the patient was escorted from the hospital in custody of the Sheriff's Department accompanied by the staff from the juvenile rehabilitation center.

Per interview on 4/2/13 at 3:02 PM, Security Officer #1 stated s/he was not made aware of Patient #1's outpatient admission prior to the first Code 8 being called on 11/7/12 or that the patient was in the custody of 2 staff members from the juvenile rehabilitation center. S/he did confirm a request was made from the juvenile rehabilitation center staff to unclasp, remove and reapply the handcuffs on Patient #1. Although handcuffs are prohibited for use by hospital staff to restrain patients, the cuffs were removed and then reapplied by the Security staff. Per interview on 4/2/13 at 12:48 PM, the Director of Security, Safety and Parking confirmed there was a lack of communication regarding notification to all Security Officers and hospital departments of Patient #1's arrival and circumstances on 11/7/12. When asked if s/he was aware of what authority staff from the juvenile rehabilitation center had in regards to the oversight of Patient #1, the Director stated the patient was in some sort of "custody". Both Security Officer #1 and the Director acknowledged most staff accompanying patients in custody arrive in a uniform, with a badge and identification. However, staff from the juvenile rehabilitation center were not in uniform and there was a failure by hospital Security to confirm the role of staff accompanying Patient #1 during the outpatient treatment provided. Within documentation reviewed, staff from the juvenile detention center were described in Patient #1's record by hospital staff as "counselors, guards and guardian". Per review of "Consent to Treat" signed by one of the staff members from the juvenile rehabilitation center identifies himself/herself as a "youth counselor", during the provision of authorization for the hospital to conduct treatment/procedures for Patient #1. The Director for Security, Safety and Parking initially described the staff from the juvenile rehabilitation center as "guards", but when informed juvenile rehabilitation center staff identified themselves in writing as a "youth counselor", the Director acknowledged s/he did not know if that was the same thing as a guard.

On 4/2/13 at 1:30 PM accompanied by the PACU Nurse Manager and PACU Nurse #1 the "bays" in PACU where patients recover from anesthesia were in close proximity of each other. It was confirmed during interview on 4/2/13 at 10:43 AM by the PACU Nurse Manager, due to the limited notification from Endoscopy prior to Patient #1's arrival, PACU staff had limited time to prepare for a safe environment, allowing for consideration where Patient #1 would be able to recover without being out among other recovering patients, allowing for a quiet more isolated and controlled location. However, the availability of the one isolation room was unknown, Patient #1 was placed in bay #49. Patients were at times opposite and beside Patient #1 during which time they were subjected to two Code 8 episodes, physical altercations by the patient on security, Patient #1's attempts at self injurious behavior along with screaming, yelling and the appearance of the Sheriff's Department. PACU nursing staff lacked a full awareness of precautions required when providing care to patients in custody especially individuals with violent and self destructive behaviors. Individuals from the juvenile rehabilitation center were not appraised of their responsibilities upon arrival to the hospital, or assigned a radio as they accompanied Patient #1 in the ED, Endoscopy and PACU and hospital staff failed to verify the authority of these individuals dictating use of handcuffs and leg shackles.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, handcuffs, which are prohibited for use by hospital staff to restrain patients, were utilized by Security Staff on 1 applicable patient. (Patient #1) Findings include:

Per review on 4/3/13, Patient #1, [AGE], was brought to the Emergency Department (ED) on 11/7/12 at 1242 after ingesting a foreign body. The patient had a past history of self injurious behaviors with previous ingestion of foreign objects including pencils and a toothbrush. Patient #1 arrived wearing leg shackles and handcuffs and was accompanied by staff from a State juvenile rehabilitation center (a center used for short-term detention for youths and also operates a secure treatment program for youths). ED note written by EMT states at 12:42 "Coming from X for vomiting blood after swallowing object. Hx. of same. Will be in handcuffs and restrained. ED security aware". Patient required Endoscopy and was transferred after the Endoscopic procedure to PACU to recover from anesthesia and to return to the juvenile rehabilitation center

Shortly after Patient #1's PACU admission, staff from the juvenile rehabilitation center, who had accompanied Patient #1 since admission to the hospital, requested to see the patient with the intent of reapplying handcuffs, the leg shackles had remained on the patient. When the handcuffs were applied by staff from the juvenile rehabilitation center, Patient #1 began yelling and kicking and attempted to ingest a plastic allergy bracelet applied earlier by hospital staff. A Code 8 was called, security and support staff responded and assisted nursing staff in removing the bracelet from Patient #1's mouth. As a result of this incident, it was determined by staff from the juvenile detention center to remove the handcuffs, place Patient #1's hands behind his/her back and then reapply the handcuffs. Due to Patient #1's agitated behavior whenever staff from the juvenile rehabilitation center approached Patient #1, they requested the hospital Security officers unclasp and remove the left handcuff and reapply it behind Patient #1's back. The Security officers complied despite the fact they are prohibited from using handcuffs as a restraint.

Per interview on 4/2/13 at 3:02 PM Security Officer #1 stated "We are not supposed to assist law enforcement with whatever restraint they are attempting to place....our role would just be to assist if person became violent. Yes, we did cuff her/him......they asked us to and s/he (Patient #1) was completely out of control when s/he (staff from the juvenile rehabilitation center) came near her/him".
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to identify a quality deficient practice involving
staff compliance with Security policies and procedures and the impact on patient safety during the provision of care of a prisoner patient brought for hospital treatment. Findings include:

For the purpose of assuring the safety of hospital staff and patients the hospital has a policy outlining the procedures Security staff are to follow when a prisoner patient is brought for treatment, however on 11/7/12, Security Staff failed to adhere to Policy "Sec /Prisoner Patient" last updated 3/11/11. Per policy, hospital staff or outside police departments or correctional facilities are to notify the Security Shift supervisor whenever a prisoner is brought to the hospital for inpatient or outpatient treatment. The prisoner patient's level of security would be determined, assessing the level of restraints being used. Communication would be made to other Security officers, alerting them of any special precautions. The policy further states: "If a correction officer, private security officer, or other law enforcement official will be supervising or sitting with the inmate, the Security shift supervisor will issue him/her a Security radio and inservice him/her on their radio call number, and the information sheet...".

Per review on 4/3/13, Patient #1, [AGE], was brought to the Emergency Department (ED) on 11/7/12 at 1242 after ingesting a foreign body. The patient had a past history of self injurious behaviors with previous ingestion of foreign objects. Patient #1 arrived wearing leg shackles and handcuffs and was accompanied by staff from a State juvenile rehabilitation center (a center used for short-term detention for youths and also operates a secure treatment program for youths). ED note written by EMT states at 12:42 "Coming from XXXX for vomiting blood after swallowing object. Hx. of same. Will be in handcuffs and restrained. ED security aware". Patient required Endoscopy and was transferred after the Endoscopic procedure to PACU to recover from anesthesia with the plan to return Patient #1 to the juvenile rehabilitation center.

During the course of recovery in PACU, two Code 8's were initiated when Patient #1's behavior was endangering the physical well being of himself/herself and other patients. At the completion of a Code 8, staff involved conduct a debriefing. This process was confirmed with the Director of Regulatory Readiness who confirmed on 4/2/13 at 1:12 PM a "....debriefing is a huddle between people involved in Code 8....to discuss the incident and any opportunities for improvement.....One of the questions is: was it safe". It was also confirmed staff within the QA/PI program were not aware of the hospital policy associated with prisoner patients and the required notification of the Security department when a prisoner patient is either inpatient/outpatient receiving care and services. As a result, when a review was conducted of the Code 8's and the Safe Report (a report of an adverse event) completed by the Nurse Manager of PACU, there was a failure to identify the lack of compliance with policy Sec /Prisoner Patients. In addition, it was also only brought to the attention of Regulatory staff during interview with Security Guard #1 on 4/2/13 , that s/he had participated with the application of handcuffs applied to Patient #1 which are prohibited for use by hospital staff to restrain patients.

It was also noted, despite the significance of events which had transpired on 11/7/12, the potential impact on patient safety, the injury to a Security guard, the lack of awareness of hospital policy regarding the management of prisoner patients, the PACU Nurse Manager confirmed on 4/2/13 at 2:15 PM, this event was not formerly shared with other PACU nursing staff as an opportunity for improvement. Although s/he had completed a Safe Report, the only clinical outcome from which it was determined if Patient #1 returned for further treatment hospital staff should "...put wrist bands other then the wrist so s/he can't eat it".