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.

BRATTLEBORO MEMORIAL HOSPITAL 17 BELMONT AVE BRATTLEBORO, VT 05301 Jan. 18, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review the Condition of Participation: Patient Rights was not met by the failure of the hospital to protect and promote each patients' rights.
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 each patient has the right to receive care in a environmentally safe setting, with respect and dignity and staff support for the patient's emotional health and physical conditions. ( Patient #1 ) Findings include:

Per record review, Patient #1 was admitted on [DATE] for profound hyponatremia (low sodium level). Additional diagnosis included Chronic Obstructed Pulmonary Disease (COPD), a cardiac condition and schizoaffective disorder with paranoia. Patient #1 has had prolonged previous admissions to this hospital and demonstrated challenging behaviors. During the hospital admission of 12/10/11 the
patient was placed on the 3rd floor patient unit. Further record review revealed on 12/11/11 Nurse #1 decided to deal with the patient by disarming the patient's hand held call light as a behavioral plan due to the frequency of use of the call light by Patient #1. The nurse removed the call light from the wall panel behind the patient's bed, silenced the alarm so it did not ring at the nurses' station or light up outside the patient's room. The hand held call light cord was not removed from the patient, instead the patient continued to retain the call light cord for use. Although this patient was vulnerable, as a result of health and psychiatric illness, other nursing staff who were also aware of the call bell removal failed to intervene on behalf of the patient. Later that evening the patient was found unresponsive experiencing a acute respiratory event requiring intubation and a transfer to the special care unit. Nursing staff were unable to confirm if an attempt was made by the patient to use the hand held call light, whether the patient was aware there was a call light in the side rail or whether s/he had attempted to yell for help even though Patient #1 was experiencing respiratory distress.

In addition to the nurses' lack of assuring the patient's right to receive care in a safe setting and to provide protection of the patient's physical and emotional health and safety, a physician assigned to Patient #1 on 12/11/11 suggested to the nurses to leave the hand held call light "...a arm's length away" from the patient but denied telling them to disconnect the call light. Per interview on 1/19/12 at 9:33 AM, the physician also confirmed a conversation with nursing staff regarding treating Patient #1 like "a 6 year
old". The physician stated "Only in the sense that you could re-direct (the patient) like you could a 6 year old. I found that when s/he would start yelling and screaming at the nurses that if you would go in and talk to her like a child s/he could be reasonably re-directed and accept the treatment you were trying to offer".

Interviews conducted by administrative staff noted on 12/14/11 Nurse #4 who was assigned to care for Patient #1 on 12/12/11 after the patient was transferred out of the Special Care Unit was told by the above mentioned physician that "I have no problem if you do not put the call bell where s/he can reach" . Nurse #4 informed the physician s/he would not comply with the physician's suggestion.
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 staff failed to assure all patients were free from all forms of neglect and harassment for 2 applicable patients and the hospital failed to report 2 incidents of potential patient abuse in a timely manner in accordance with State Law. (Patient #1, 2) Findings include:

1. Although the hospital has policies and procedures in place for assuring the protection of vulnerable adults, nursing staff failed to follow hospital policies and applicable State laws regarding reporting to Adult Protective Services an event involving staff neglect and indifference to patient needs.
Patient #1 was admitted on [DATE] for profound hyponatremia (low blood sodium level). Additional diagnosis includesd Chronic Obstructed Pulmonary Disease (COPD), a cardiac condition and schizoaffective disorder with paranoia. Patient #1 has had prolonged previous admissions to this hospital and demonstrated challenging behaviors. During the hospital admission of 12/10/11 the patient was placed on the 3rd floor patient unit. Further record review revealed on 12/11/11 Nurse #1 decided to deal with the patient by disarming the patient's hand held call light as a behavioral plan due to the frequency of use of the call light by Patient #1. The nurse removed the call light from the wall panel behind the patient's bed, silenced the alarm so it did not ring at the nurses station or light up outside the patient's room. The hand held call light cord was not removed from the patient, instead the patient continued to retain the call light cord for use. Although this patient was a vulnerable adult with both physical and mental disabilities, other nursing staff who were also aware of the action failed to intervene on behalf of the patient. Later that evening the patient was found unresponsive requiring emergent intubation and a transfer to the special care unit. Nursing staff were unable to confirm if an attempt was made by the patient to use the hand held call light, whether the patient was aware there was a call light in the side rail or whether s/he had attempted to yell for help even though Patient #1 was experiencing respiratory distress.

Although a report was eventually made to the State Adult Protective Services (APS) Program by the hospital over a month after the incident, it did not meet the time requirements of Title 33: Human Services, Chapter 69: Reports of Abuse, Neglect and Exploitation which requires a report be filed with the State agency within 48 hours of knowing an event of abuse, neglect or exploitation has occurred. In addition, staff failed to follow hospital policy "Abuse of Vulnerable Adult" last reviewed 12/22/11 which also requires staff to follow State Statute for reporting a suspicion of abuse.

2. Per review on 1/19/12 of a nurse's personnel record an event involving the nurse and a vulnerable elderly patient had occurred on 6/20/11 which required a report to Adult Protective Services. Per review of a family complaint, the nurse was overheard being "angry and hostile" toward an elderly female patient. The nurse was heard yelling " I don't have time to come in here every 2 minutes" and "S/he needed to tell him/her everything at once when s/he (the nurse) came in the (patient's) room". The nurse was also overheard noting to the patient that they were "wet". The documentation later stated the patient developed "CHF" (Congested Heart Failure) later on the same day. The complainant in this incident reported they were afraid to leave their elderly parent at the hospital, expressing fear for their parent's physical and mental condition if this nurse was assigned to their family member. Per interview on the afternoon of 1/19/12, the Director of Medical/Surgical units confirmed a report to APS was not made despite their awareness of the required reporting process.
VIOLATION: QAPI Tag No: A0263
Based on survey findings, the Condition of Participation for Quality Assessment and Performance Improvement Program was not met based on deficiencies cited relating to Nursing Services and Patient Rights, and the failure to assure policies were implemented and an accurate and timely review was conducted of an Adverse Patient Event.

Refer to Tags: A-0144; A-0145; A-0395
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record review and staff interview, the hospital failed to ensure that staff consistently implemented the Event Reporting policy and failed to develop and implement an action in response to a previously identified quality deficient practice, to ensure the deficient practice did not recur. Findings include:

Per interview on 9:04 AM on 1/18/11, the Director of Medical and Surgical units confirmed s/he was notified on 12/14/11 by a nurse of an adverse patient event which had occurred on the 3rd floor nursing unit on 12/11/11. As a result of the information obtained, the Director notified the Director of Human Resources/Compliance Officer and the Director of Risk Management on 12/14/11. Subsequent notifications were made to made to the Director of Quality and Care Manager, Vice President of Clinical Services, CEO and the Chief Medical Officer. Interviews were conducted with nursing staff, administrative action with an employee was initiated and an investigation of the event was conducted. However, although a significant deficient practice was identified, the hospital failed to assure the circumstances and attitude associated with the event was not hospital wide. As of 1/19/12 over a month since the event, hospital wide education had not been conducted, and preventive actions were not implemented to assure Patient Rights were preserved and maintained, standards of nursing practice consistently met; and re-education provided regarding the provision of safe patient care.

It was also confirmed, although more then one nurse had been made aware of the adverse event which put a patient at risk, an adverse event report had not been completed by staff on the night of the event. When Department Leaders were made aware of the event of 12/11/11 the process for reporting was also not followed as per hospital policy "Incident Report -Patient/Visitor (last reviewed 3/30/2011) states "Staff are encouraged and expected to file an incident report when events occur that impact patient care, management and treatment".

Refer to Tags: A-0144; A-0145, A-0395
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observations, staff interview and record review, the Condition of Participation for Nursing Services was not met due to the failure of nursing staff to meet accepted standards of nursing practice, to follow hospital policy and by failing to maintain a safe patient environment.

Refer to Tag 0395
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, staff interviews and record review, nursing staff failed to meet accepted standards of nursing practice and follow hospital policy when a patient with significant health issues and a fall risk was purposely denied the use of their call light creating a threat to patient safety. ( Patient #1 ) Findings include:

On 12/11/11 a RN disabled a hand held call light used by a patient who was admitted on [DATE] for profound hyponatremia (low sodium level), COPD, significant cardiac disease and schizoaffective disorder. Later in the evening of 12/11/11, Patient #1 was found in severe respiratory distress requiring intubation and transfered to the special care unit for life support intervention.

Per interview on 1/18/12 at 9:05 AM, the Director of the Medical/Surgical units confirmed s/he was informed by Staff Nurse #2 on 12/14/11 Staff Nurse #1 had decided to remove the hand held call bell used by Patient #1 to prevent the patient from calling the nurses station. During the Director's internal investigation of the event s/he was informed other nurses were also aware Patient #1, who frequently used the hand held call light for multiple reasons, was unable to use the call light for a undisclosed period of time on 12/11/11. When interviewed by the Director, Staff Nurse #1, who worked the 7 AM to 7 PM shift, described the disabling of Patient #1's hand held call light as a "behavioral plan" and further commented "everyone knew about it". Per observation at 10:35 AM on 1/18/12, the disabling of the hand held call light was demonstrated by the Director of the Medical/Surgical units. Staff Nurse #1 had removed the connecting cord from the wall outlet, applied a button attachment to the wall outlet (which would silence the call light from ringing at the nurses station and outside the patient's room ). Although disabled, the hand held call light cord was not removed from the patient. Staff reported during interviews, Patient #1 was known to continuously hold the call bell cord in their hand.

Per review of an interview conducted by the Director of Medical/Surgical on 12/15/11, Staff Nurse #1 defended his/her actions for disabling the hand held call light on 12/11/11 stating Patient #1 still had access to the side rail call lights and had his/her voice to call the nurse if necessary. (Patient #1's room was located at the far end of the unit hallway and the greatest distance from the nurses station). An interview with nursing staff on 1/18/12, confirmed upon admission patients are instructed to use the hand held call light, which also controls the patient's TV. Per interview on 1/18/12 at 10:50 AM, Staff Nurse #3 stated although s/he tells the patient about the call light on the side bed rail, s/he always tells them to use the hand held call bell stating the side rail call bell does not always work. The tenuous functioning of the bed rail alarm was reconfirmed by 2 other staff nurses assigned to the third floor unit who, upon patient admission to the third floor unit, always instruct patients to use the hand held call bell.

The ability of Patient #1 to use the side rail call bell could not be confirmed. What was known on 12/11/11, Patient #1 was assessed by Nurse #1 and recorded on the "M S Physical Assessment"at 16:45 to be anxious, with shortness of breath with exertion, with generalized weakness, mobility was very limited, mental status was confused/agitated and was identified to be a high fall risk. Per Physician discharge summary, Patient #1 was described upon admission to be "delusional".

A Progress note for 12/11/11 states "Nursing note re: Rapid Response. Entered pts' room @about 11 PM to address alarming IV pump. Pt. found unresponsive and grey in color....". Pt required intubation to assist with breathing and was transferred to the special care unit. Within 24 hours Patient #1 was breathing on his/her own. Per interview on 1/18/11, the Director of Medical/Surgical units also confirmed nurses who had an awareness of the incident of 12/11/11 failed to intervene on behalf of the patient, did not file an adverse event report or contact the Nursing Supervisor on 12/11/11 or alert administrative staff regarding the call bell issue. It was not until 12/14/11 when Staff Nurse #2 expressed patient safety concerns the incident surrounding the disabling of the call bell became known to hospital administrative staff.

Refer to Nursing Standards of Practice: Lipincott, Manual of Nursing Practice, 9th edition; Chapter 2, "Standards of Care, Ethical and Legal Issues", Page 13; National League of Nursing Statement on Patient Rights.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on record review and interview, the nursing care plan failed to address a patient's behaviors along with interventions to reduce the agitation and anxiety and also failed to address the patient's fluid restrictions for 1 applicable patient (Patient #1) Findings include:

1. Per review of Patient #1's medical record on 1/19/12, previous hospital admissions note patient has a history of behaviors which have challenged nursing staff during the provision of care and services. Due to a psychiatric disorder with symptoms of paranoia, anxiety and agitation, delivering services required an interdisciplinary approach. The nursing care plan did not reflect any interventions regarding approaching the patient, promoting use of stress reduction techniques or establishing a consistent care approach when addressing the patient's demands and refusal of care. In addition, at the time of admission Patient #1 was diagnosed with "profound hyponatremia" (extremely low blood sodium level). The care plan did not reflect physician orders for fluid restriction and monitoring of Patient #1's intake and output to include the infusion of normal saline and the patient's response to the infusion. There was also no evidence in the patient's clinical flow sheets, that upon admission, staff were monitoring the patient's intake and output. This omission was confirmed durng an interveiw on the morning of 1/19/12 with the Manager of Medical/Surgical units.