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 05301 July 16, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
The Condition of Participation: Patient Rights was not met as evidence by the failure of the hospital to provide an environment that promoted and protected the physical and emotional well being and safety for all patients; failed to protect a patient from being tazed and handcuffed by police and also failed to assure the patient's rights remained intact and under the protection of the hospital and not relinquished to police authority during a non law enforcement intervention.

Refer to Tags: A-0 144, A-0154, A-0164
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observations, interview and record review, the hospital failed to assure care was provided in an environment that promoted and protected the physical and emotional well being and safety for all patients. Findings include:

On 5/23/13 Patient #1 was admitted with a diagnosis of Schizophrenia and mood dysregulation and a recent history of a violent assault prior to admission. Physician progress notes describe Patient #1 as psychotic, delusional and at times threatening. A nursing progress note for 7/3/13 at 1:17 PM Patient #1 was described as "uncooperative, suspicious, hostile" and "...very psychotic, expressing a lot of violent thoughts, threats to both staff and patients....". The attending psychiatrist progress note for 7/3/13 states "Patient had silent code called this am....very threatening verbal behaviors and physical posturing. Did respond to prn Klonopin......Patient is very psychotic, believes s/he has killed many people, was in Hitler youth, special forces ect". Decision on 7/3/13 by the treatment team was not to place Patient #1 in ALSA (Adult Low Stimulation Unit) but to be allowed to remain in the general milieu despite concerns voiced by patients and some staff.

Per interview on 7/16/13 at 8:26 AM, Mental Health Worker (MHW) #1 stated "Day before (7/3/13) there was a collection of 2-3 women patients scared to death of him/her. (Patient #1) They voiced that. Asking the staff to intervene". Per MHW progress note for 7/3/13 at 10:52 AM states "Patient wandering through unit halls 'I'm going to rape her'. Patient did not disclose who 'her' is "'. Per interview on 7/16/13 at 9:05 AM, MHW #2 acknowledged it was on 7/3/13 when Patient #1 "... started to escalate". The policy describing the assessment criteria for admission to ALSA (last updated 05/2013) states clinical concerns related to "High risk for violence: Recent assualtiveness towards staff or other patients...or a history of assault or violence that suggests a current high risk for such actions. These individuals pose a risk for violence or aggression even when in the general milieu of an inpatient unit, and thus require special attention". Per interview on 7/16/13 at 10:23 AM, the attending psychiatrist confirmed the patient "...was extremely psychotic. S/he was threatening to staff" and had initially ordered the patient to be placed in ALSA, however decided after speaking with Patient #1 and providing an additional Klonopin the order was discontinued allowing the patient to remain in the general milieu. It was the impression of the psychiatrist, Patient #1 would relate to a ALSA transfer as "punitive".

Per nursing progress note for 7/4/13 " At 8:22 AM silent code called because patient was making verbal threats and threw a chair in the community area. At 8:30 AM, patient was given Klonopin 2 mg with little effect. At 9:10 AM, Patient was throwing air punches at another patient's face." The charge nurse for Tyler -2 for 7/4/13 further stated in a report of events "Today, (the patient) was announcing with hostile edge to both staff and clients in community area that s/he planned to assault someone. S/he postured and stared angrily at women and men as s/he clinched fist and verbalized threats." Interventions were attempted by staff, with the exception of a transfer to ALSA, to redirect Patient #1, however the patient did not respond and continued to threaten while remaining in the general milieu among other Tyler-2 patients.

At approximately 9:15 AM on 7/4/13 AM MHW #1 was standing near the nurses station and was approached from behind by Patient #1 who attempted to pour coffee on the MHW's head. The coffee cup was pushed away by the MHW and Patient #1 lunged and began physically assaulting MHW #1 with multiple punches to the back of his/her head, face and lower back. On 7/16/12 at 8:35 AM MHW #1 stated "S/he came in with repetitive blows, pummeling my head...his/her arms were coming in from both sides. There was no escape..... thought I would loose consciousness." At the time of the incident other male and female MHWs were off the unit responding to other Code Greens (rapid response to a safety emergency). Female nurses began yelling and screaming at the patient to stop and a Code Green was called. When additional staff finally arrived, Patient #1 stopped the assault and proceeded to walk on his/her own, per direction of staff, into ALSA where s/he was placed in locked door seclusion at approximately 9:22 AM. Within minutes of placing the patient in seclusion, nursing and on-call psychiatrist determined patient required emergency medications. An order for Thorazine 200 mg Intramuscular (IM) was ordered at 9:35 AM. Per interview on 7/16/13 at 11:09 AM, RN #1 stated "S/he (the patient) wasn't willing to take medication voluntarily". Per interview on 7/16/13 at 1:40 PM the Supervisor for Security Services stated there was 4 male MHW, 2 security guards and 6 female staff (including nurses and MHWs). However, the Security Supervisor stated "We are not equipped to handle a patient this size and strength..." The decision was made by the charge nurse and the Supervisor for Security Services to contact the Brattleboro Police to assist with the application of a therapeutic hold for the administration of the IM medication. Regarding the request for the police, RN #1 further stated "We wanted them for a show of support". One officer arrived at 9:50 AM and a second officer by 10:00 AM.

Per review of policy and procedure Safety Emergencies: Restraint, Seclusion and Therapeutic Holding of Patients last reviewed 04/2013 states: "All safety interventions shall be conducted in a safe, humane, and effective manner, without intent to harm or create undue discomfort for the patient while preserving the patient's dignity". However, at 10:05 AM the door to the seclusion room was unlocked and opened. The 2 police officers and one nurse stood in the doorway and the patient was informed emergency medication was going to be administered. Other hospital staff remained in the hallway of the ALSA and did not approach Patient #1. With the appearance of the police and being informed of the impending administration of medication, Patient #1 charged towards the doorway. One of the officers proceeded to utilize a Tazer gun, emitting an electrical discharge by deploying probes and fine wires that made contact with Patient #1's right side and right arm. Patient #1 fell towards the mattress in the seclusion room and was brought to the mattress and then handcuffed behind his/her back by the police officers. Nursing staff then proceeded to administer to Patient #1 200 mg of Thorazine IM. Shortly after, the hospital clinic was notified that medical assistance was needed for the removal of the tazer gun probes. At 10:16 AM, A licensed independent practioner arrived to the unit and assisted with the removal of one of the probes imbedded in the patient's right arm and first aid applied to other taser sites. Patient #1 remained in locked door seclusion until 5:10 PM and continued to be retained in ALSA.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on staff interview and record review, the hospital failed to protect a patient's rights when a weapon (tazer) was used to subdue the patient and handcuffs applied for the purpose of administering emergency involuntary medication while the patient was in seclusion. The hospital also failed to assure the patient's rights remained intact and under the protection of the hospital and not relinquished to police authority. (Patient #1) Findings include:

At approximately 9:15 AM on 7/4/13 AM MHW #1 was standing near the nurses station on Tyler 2 and was approached from behind by Patient #1 who attempted to pour coffee on the MHW's head. The coffee cup was pushed away by the MHW and Patient #1 lunged and began physically assaulting MHW #1 with multiple punches to the back of his/her head, face and lower back. Per interview on 7/16/12 at 8:35 AM MHW #1 stated "S/he came in with repetitive blows, pummeling my head...his/her arms were coming in from both sides. There was no escape... thought I would loose consciousness." After the assault, Patient #1 walked with staff unassisted into ALSA area and into the seclusion room which was then locked at approximately 9:22 AM.

Additional staff arrived on the unit including 4 male MHW, 2 male security guards and 6 female nurses and MHWs who remained within the ALSA common area outside the seclusion room. At times Patient #1 would stand in the corner of the seclusion room and at other times s/he would kick the door or Plexiglass observation window and yell threats to staff. After consultation with the "on-call psychiatrist" an order for an emergency medication, Thorazine 200 mg. IM was offered and refused by the patient. It was then decided to contact the local police to request assistance. Although MHWs, nursing and Security staff have received training in CPI (Crisis Prevention Training) to ensure a safe environment by providing interventions during a safety threat or emergency, staff choose to request police assistance with the administration of the emergency medication. Per interview on 7/16/13 at 1:40 PM, the Supervisor for Security Services stated "We were not equipped to handle a patient this size and strength...." and stated when police have been called to the hospital in the past, "Just their presence, patients would do as directed". One police officer arrived at the hospital at 9:50 AM on 7/4/13 and an additional police officer arrived by 10:00 AM. At 10:05 AM, the door to the seclusion room was opened and the 2 police officers and the charge nurse stood in the doorway and informed Patient #1 the staff planned on administering IM Thorazine and told the patient to lay on the mattress. Again the patient refused and proceeded to charge the doorway of the seclusion room. Per interview on 7/16/13 at 9:40 AM, MHW #3 stated "One of the officers had his/her tazer drawn behind his/her back the whole time". One of the officers proceeded to utilize a tazer gun, emitting an electrical discharge by deploying probes and fine wires that connected to Patient #1's right side and right arm. Patient #1 fell towards the mattress in the seclusion room and was brought to the mattress and was then handcuffed behind his/her back by the police. Once secured, Patient #1 received IM injections of 200 mg of Thorazine. The patient remained handcuffed for approximately another 10 minutes and then the handcuffs were removed by the police. Shortly after, the hospital clinic was notified that medical assistance was needed for the removal of the tazer gun probes. At 10:16 AM, A licensed independent practioner arrived to the unit and assisted with the removal of one of the probes imbedded in the patient's right arm and first aid applied to other tazer sites. Patient #1 remained in locked door seclusion until 5:10 PM and continued to be retained in ALSA away from the general milieu of the unit. .
Per hospital policy, Police Response to Safety Emergencies last reviewed 03/2013 states "Only when Brattleboro Retreat approved safety interventions have failed shall there be a process for requesting assistance from the Brattleboro PD". The policy also states " The responding officers have the authority to determine that they must take control of the safety emergency and to intervene according to police procedures." In this case, no other safety interventions were attempted by staff. The hospital staff relinquished their responsibility to ensure the safety of the patient by permitting the police officers to respond to a non-law enforcement situation and utilize a weapon and handcuffs for the purpose of administering medication by achieving a therapeutic hold on Patient #1. Per interview on 7/16/13 at 1:40 PM, the Supervisor for Security Services confirmed in the past when police assistance has been requested at the hospital, they were utilized as a "show of force" and is sufficient to get a patient "....to do as directed".
By handing over the decision making process to police officers to manage the critical incident involving Patient #1, the hospital failed to support the patient's right to receive safe and appropriate care in a safe environment. Patient # 1 was not in police protective custody, nor a prisoner, but a patient with significant psychiatric disabilities that required direct management and consistent therapeutic intervention by hospital staff. Being subjected to the electrical discharge from a taser gun and restrained by handcuffs by police officers placed the patient in imminent danger and jeopardized the patient's rights.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
Based on record review and staff interview the hospital failed to assure the least restrictive intervention was initiated prior to the implementation of police action resulting in the use of a weapon (tazer) and handcuffs for one applicable patient. (Patient #1) Findings include:

On 5/23/13 Patient #1 was admitted with a diagnosis of Schizophrenia and mood dysregulation and a recent history of a violent assault prior to admission. Physician progress notes describe Patient #1 as psychotic, delusional and at times threatening. A nursing progress note for 7/3/13 at 1:17 PM Patient #1 was described as "uncooperative, suspicious, hostile" and "...very psychotic, expressing a lot of violent thoughts, threats to both staff and patients....". The attending psychiatrist progress note for 7/3/13 states "Patient had silent code called this am....very threatening verbal behaviors and physical posturing. Did respond to prn Klonopin......Patient is very psychotic, believes s/he has killed many people, was in Hitler youth, special forces ect". Decision on 7/3/13 by the treatment team was not to place Patient #1 in ALSA (Adult Low Stimulation Unit) but to be allowed to remain in the general milieu despite concerns voiced by patients and some staff.

Per interview on 7/16/13 at 8:26 AM, MHW #1 stated "Day before (7/3/13) there was a collection of 2-3 women patients scared to death of him/her. . They voiced that. Asking the staff to intervene". Per MHW progress note for 7/3/13 at 10:52 AM states "Patient wandering through unit halls 'I'm going to rape her'. Patient did not disclose who 'her' is "'. Per interview on 7/16/13 at 9:05 AM, MHW #2 acknowledged it was on 7/3/13 when Patient #1 "... started to escalate". The policy describing the assessment criteria for admission to ALSA (last updated 05/2013) states clinical concerns related to "High risk for violence: Recent assualtiveness towards staff or other patients...or a history of assault or violence that suggests a current high risk for such actions. These individuals pose a risk for violence or aggression even when in the general milieu of an inpatient unit, and thus require special attention". Per interview on 7/16/13 at 10:23 AM, the attending psychiatrist confirmed the patient "...was extremely psychotic. S/he was threatening to staff" and had initially ordered the patient to be placed in ALSA, however decided after speaking with Patient #1 and providing an additional Klonopin the order was discontinued allowing the patient to remain in the general milieu among the other patients. It was the impression of the psychiatrist, Patient #1 would relate to a ALSA transfer as "punitive".

Per nursing progress note for 7/4/13 " At 8:22 AM silent code called because patient was making verbal threats and threw a chair in the community area. At 8:30 AM, patient was given Klonopin 2 mg with little effect. At 9:10 AM, Patient was throwing air punches at another patient's face." The charge nurse for Tyler -2 for 7/4/13 further stated in a report of events "Today, (the patient) was announcing with hostile edge to both staff and clients in community area that s/he planned to assault someone. S/he postured and stared angrily at women and men as s/he clinched fist and verbalized threats." Interventions were attempted by staff, with the exception of a transfer to ALSA, to redirect Patient #1, however the patient did not respond and continued to threaten while remaining in the general milieu among other Tyler-2 patients.

At approximately 9:15 AM on 7/4/13 AM MHW #1 was standing near the nurses station and was approached from behind by Patient #1 who attempted to pour coffee on the MHW's head. The coffee cup was pushed away by the MHW and Patient #1 lunged and began physically assaulting MHW #1 with multiple punches to the back of his/her head, face and lower back. On 7/16/12 at 8:35 AM MHW #1 stated "S/he came in with repetitive blows, pummeling my head...his/her arms were coming in from both sides. There was no escape..... thought I would loose consciousness." At the time of the incident other male and female MHWs were off the unit responding to other Code Greens (rapid response to a safety emergency). Female nurses began yelling and screaming at the patient to stop and a Code Green was called. When additional staff arrived, Patient #1 stopped the assault and proceeded to walk on his/her own, per direction of staff, into ALSA where s/he was placed in locked door seclusion at approximately 9:22 AM.

Within minutes of placing the patient in seclusion, nursing and on-call psychiatrist determined patient required emergency medications. An order for Thorazine 200 mg Intramuscular (IM) was ordered at 9:35 AM. Per interview on 7/16/13 at 11:09 AM, RN #1 stated "S/he (the patient) wasn't willing to take medication voluntarily". There had been no attempt to employee less restrictive measures to de-escalate the patient's behavior. Per interview on 7/16/13 at 9:03 AM MHW #2 stated prior to police arrival and encounter Patient #1 was, at times, standing quietly in the corner of the seclusion room and at other times yelling at staff and kicking the door of the seclusion room. Per MHW #3 on 7/16/13 at 9:38 AM also stated before police arrived Patient #1 was "...really quiet....was actually doing very well....the assault had already happened" (referring to incident involving MHW # 1). Per report completed by the charge nurse of events on 7/4/13, Patient #1 expressed delusional comments shouting "No Tear gas". Instead, the decision was made by the charge nurse and the Supervisor for Security Services to contact the Brattleboro Police to request assistance with the application of a therapeutic hold for the administration of the involuntary emergency medication. One officer arrived at the hospital at 9:50 AM and a second officer by 10:00 AM.

With the appearance at the doorway of the seclusion room of the 2 police officers and the charge nurse and being informed of the impending administration of medication, Patient #1 charged towards the doorway. One of the police officers proceeded to utilize a Tazer gun, emitting an electrical discharge by deploying probes and fine wires that made contact with Patient #1's right side and right arm. Patient #1 fell towards the mattress in the seclusion room and was brought to the mattress and handcuffed behind his/her back by the police. Nursing staff then proceeded to administer to Patient #1 200 mg of Thorazine IM and the patient remained secured in locked seclusion. Per hospital policy Safety Emergencies: Restraint, Seclusion and Therapeutic Holding of Patients last reviewed 04/2013, states "In the circumstance that all Retreat resources have been made available and the patient situation remains dangerous it may be necessary to call for assistance from Brattleboro police". However, in this incident, resulting in a weapon and handcuffs being utilized on a patient, there was no clear evidence all resources had been made available and utilized by hospital staff prior to seeking the assistance of the police. In addition, staff then permited the police to manage and control circumstances for the administration of emergency medication.