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 RETREAT ANNA MARSH LANE PO BOX 803 BRATTLEBORO, VT Oct. 22, 2013
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on interview and record review, the hospital failed to ensure each patient's individual rights were maintained by staff during random contraband searches identified by the hospital to be necessary in preventing unsafe articles from entering a patient unit. Findings include:

The hospital polices and procedures pertaining to the Disposition of Unsafe Items, last approved 12/2012, was developed for the purpose of assuring patients are receiving treatment "...in an environment that is free of any items or substances that are potentially harmful or actually harmful" and that subjects of patient searches "...will have his/her dignity and privacy and confidentiality maintained...." and "...will demonstrate the utmost sensitivity and respect..." during the search process. However, per interview on 10/22/13 at 11:23 AM a nurse on Tyler 3 confirmed the unit does their own specific searches which includes random contraband searches of adolescents whenever they have been off the unit. Prior to being allowed to return to the unit each patient is required to empty their pockets while being detained in the elevator alcove. When a group of patients return to the unit, in addition to the pocket search a random safety check is also conducted. Patients are directed by Tyler 3 staff to pick from a covered container one piece of colored paper. Depending on the color chosen, patients who had unknowingly choose the color red are then subjected to a search by staff. Despite the fact that a randomly chosen patient did not attempt to hide contraband or have a history of such behavior they would still be subjected to the search. A "search" for body contraband can include checking shoes and socks, removing a sweatshirt and rolling down waistbands and shaking out their hair. Although this protocol has been utilized as an attempt to prevent self injurious behaviors by discouraging patients from bringing sharp objects or other unsafe articles back on the unit, it does not preserve each patient's right to not be subjected to unwarranted search without just cause, clinical need or as directed per each patient's individualized behavioral/treatment plan.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observations and interviews, the hospital failed to assure each patient's right to receive care in a safe setting by failing to identify a potential safety hazard on Tyler 3. Findings include:

On 10/22/13 at 2:00 PM a tour was conducted of Tyler 3 to observe environmental changes made by the hospital in an effort to maintain a safe environment for the adolescent population. Observation of the phone booth noted the door window to the phone booth was replaced with wood. This obstruction prevented staff ability to visualize patients during safety checks when a patient was utilizing the phone when the door to the booth is closed. Further observation noted, upon standing on the bench in the phone booth, a patient had easy access to a fire sprinkler head which had sharp edges and protrusions. The observation was confirmed by the unit nurse manager and a member of the maintenance department.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interview and record review, the hospital failed to ensure staff, identified as mandated reporters, who became aware of an allegation of abuse, reported the allegation to the appropriate State Agency, as required, for 1 applicable patient. (Patient #2)
Findings include:

Per record review of Nursing Notes for Patient #2 from 9/4/13 "Patient had both verbal and physical altercation (tried to choke) male peer", and Mental Health Worker notes for the same day record Patient #2 as "mostly disruptive, disrespectful, noncompliant and assaultive towards peer ...trying to choke peer". Per record review of Physician Notes from 9/5/13, Patient #2 "engaged in a physical altercation with peer last evening ...responded by placing h/her hands around peer's neck. Staff intervened and patient was placed on assaultive behavior protocol". Per interview on 10/22/13 at 9:30 A.M. Patient #2's Social Worker confirmed placing Patient #2 on assaultive behavior protocol indicated that the patient choking his/her peer was a serious incident and confirmed it should have been reported to the appropriate state agency.

Per interview with the Director of Social Services on 10/22/13 at 9:30 A.M., if there is an assault or incident on Patient #2's unit, a report would be made to the Department of Children and Families (DCF) during the shift the incident occurred, in order to comply with DCF requirements that allegations of abuse be reported within 24 hours. (<http://dcf.vermont.gov/fsd/reporting_child_abuse>)

Per interview on 10/22/13 at 12:55 P.M. the Manager of Performance Improvement and Risk Management stated it was his/her expectation that this incident would be reported to DCF and the reporting would be documented. The Manager confirmed s/he had not found any evidence or documentation that this specific assault by Patient #2 on 9/4/13 had been reported to the appropriate State Agency.