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 Aug. 18, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record reviews conducted on days of survey, the Condition of Participation: Patient Rights was not met as evidenced by the hospital's failure to provide sufficient interventions to assure each patient's rights are protected by maintaining care in a safe setting. Findings include:

Refer to Tag: A- 144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on staff interview and record review, the hospital failed to provide sufficient interventions to assure each patient's rights are protected by maintaining care in a safe setting. Findings include:

On 7/16/14 Patient #1, with a diagnosis of Anxiety, Assaultive behaviors, PTSD and Suicidal ideation was admitted to the Tyler 3/Adolescent unit. Over the past 2 years Patient #1 had 2 prior hospitalization s and had resided in residential treatment programs for sexual offending and aggressive behaviors and self-harming behaviors. The initial physician admission assessment states Patient #1 was not only a victim of sexual abuse but also a "...perpetrator against males, females and mother." A Social Work Progress note for 7/17/14 states within "Symptoms observed/Assessment Summary:..... Patient has a history with many flags in it which bear watching most obviously sexualized actions with both males and females". In addition, the initial Social Service Assessment completed on 7/17/14 remarks: " Past/present Functioning: ...s/he has a history of sexualized behavior and can become infatuated with female staff. "

The Interdisciplinary Treatment Plan for 7/17/14 identified Patient #1 to have Impulsive Behavior manifested by a "History of sexualized behaviors toward others" however goals and treatment modalities did not address how they would assure Patient #1 maintained personal and physical boundaries with both staff and other patients. Upon admission it was determined Patient #1 would be on routine 15 minute safety checks. On 7/18/14, Patient #1 was also assigned to the Community Area (a location near the nurses station which enable staff to monitor patients at all times during daily activities). While assigned to the Community Area Patient #1 developed a relationship with an older peer, Patient #2, who was admitted for depression and has a history of being sexually, physically and emotionally abused. Patient #2's room was in close proximity to the Community Area allowing Patient #1 to sit outside or across from Patient #2's room while monitored by Tyler 3 staff. Multiple conversations transpired between Patient #1 and #2 during which time both patients declined to take part in any of the scheduled activities and support groups.

On 7/23/14 during an onsite visit to Tyler 3, staff from a residential program who were evaluating Patient #1's potential to return to their program upon discharge voiced concern to a Tyler 3 Social Worker of Patient #1's interaction with Patient #2 given the past history of inappropriate attachment with older peers and staff. On 7/24/14 a Nursing progress note at 3:35 PM states a patient informed staff that "a couple of days ago" Patient #1 had inappropriate sexual contact with Patient #2. When approached by both nursing staff and physicians, both Patient #1 and #2 denied sexual contact had occurred. Nursing progress note for 7/25/14 at 2:41 PM states Patient #2 reported to both RN and Clinical Manager that "a couple of days ago" Patient #1 had placed fingers in her vagina. A Physician Progress note for 7/28/14 states Patient #1 admitted to engaging in sexual activity with Patient #2. Once made aware of the events reported, Patient #1 was placed in ALSA (Low Stimulation Area) and on 1:1 monitoring. A Physician Progress note for 8/1/14 states Patient #1 "..has a significant history of sexual offending behaviors which require high level of supervision".

Per interview on 8/12/14 at 5 PM, the Social Worker assigned to the Treatment Team for Patient #1 confirmed although reports were made to the required State authorities and/or guardians regarding the inappropriate sexual contact, s/he was unable to provide an explanation how the event could have occurred when Tyler 3 staff were assigned to monitor Patient #1 and his/her movements/activities throughout the unit. ". Per interview on 8/13/14 at 4:30 PM, the Treatment team (Psychiatrists, Social Worker and Clinical Nurse Manager) were unable to provide any further explanation how adolescent patients requiring psychiatric hospitalization were not provided an environment that protects their vulnerability and ensures the care they require is in a safe setting. In addition, it was also acknowledged the treatment plan for Patient #1 failed to specifically address individualized actions/interventions to assist staff in the prevention of inappropriate sexual behaviors from occurring during the hospitalization of Patient #1 to ensure the safety of all patients on Tyler 3.
VIOLATION: QAPI Tag No: A0263
Based on interview and record review, the Condition of Participation for Quality Assessment and Performance Improvement (QA/PI) was not met due to the hospital's failure to assure that all staff utilized the established Incident/Occurrence reporting system to identify a potential adverse event and opportunity for improvement; and failed to fully analyze, develop and implement actions and mechanisms for learning throughout the hospital, following an identified adverse event. Findings include:
Refer to Tag: 286

This is a repeat citation.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on staff interviews and record review the facility failed to assure that all staff utilized the established Incident/Occurrence reporting system to identify a potential adverse event and opportunity for improvement; and failed to fully analyze, develop and implement actions and mechanisms for learning throughout the hospital, following an identified adverse event. Findings include:
On 7/16/14 Patient #1, with a diagnosis of Anxiety, Assaultive behaviors, PTSD and Suicidal ideation was admitted to the Tyler 3/Adolescent unit. Over the past 2 years Patient #1 had 2 prior hospitalization s and had resided in residential treatment programs for sexual offending and aggressive behaviors and self-harming behaviors. The initial physician admission assessment states Patient #1 was not only a victim of sexual abuse but also a "...perpetrator against males, females and mother." A Social Work Progress note for 7/17/14 states within "Symptoms observed/Assessment Summary:..... Patient has a history with many flags in it which bear watching most obviously sexualized actions with both males and females". In addition, the initial Social Service Assessment completed on 7/17/14 remarks: " Past/present Functioning: ...s/he has a history of sexualized behavior and can become infatuated with female staff. "

The Interdisciplinary Treatment Plan for 7/17/14 identified Patient #1 to have Impulsive Behavior manifested by a "History of sexualized behaviors toward others" however goals and treatment modalities did not address how they would assure Patient #1 maintained personal and physical boundaries with both staff and other patients. Upon admission it was determined Patient #1 would be on routine 15 minute safety checks. On 7/18/14, Patient #1 was also assigned to the Community Area (a location near the nurses station which enable staff to monitor patients at all times during daily activities). While assigned to the Community area Patient #1 developed a relationship with an older peer, Patient #2, who was admitted for depression and has a history of being sexually, physically and emotionally abused. Patient #2's room was in close proximity to the Community Area allowing Patient #1 to sit outside or across from Patient #2's room while monitored by Tyler 3 staff. Multiple conversations transpired between Patient #1 and #2 during which time both patients declined to take part in any of the scheduled activities and support groups.

On 7/23/14 during an onsite visit to Tyler 3, staff from a residential program who were evaluating Patient #1's potential to return to their program upon discharge voiced concern to a Tyler 3 Social Worker of Patient #1's interaction with Patient #2 given the past history of inappropriate attachment with older peers and staff. On 7/24/14 a Nursing progress note at 3:35 PM states a patient informed staff that "a couple of days ago" Patient #1 had inappropriate sexual contact with Patient #2. When approached by both nursing staff and physicians, both Patient #1 and #2 denied sexual contact had occurred. Nursing progress note for 7/25/14 at 2:41 PM states Patient #2 reported to both RN and Clinical Manager that "a couple of days ago" Patient #1 had placed fingers in her vagina. A Physician Progress note for 7/28/14 states Patient #1 admitted to engaging in sexual activity with Patient #2. Once made aware of the events reported, Patient #1 was placed in ALSA (Low Stimulation Area) and on 1:1 monitoring. A Physician Progress note for 8/1/14 states Patient #1 "..has a significant history of sexual offending behaviors which require high level of supervision".

Per interview on 8/12/14 at 5 PM, the Social Worker assigned to the Treatment team for Patient #1 confirmed although reports were made to the required State authorities regarding the inappropriate sexual contact, s/he was unable to provide an explanation how the event could have occurred when Tyler 3 staff were assigned to monitor Patient #1 and his/her movements/activities throughout the unit. At the time of interview the Manager of Performance Improvement and Risk Management confirmed s/he had not been made aware of the events involving Patient #1 and #2 and further confirmed an Incidence/Occurrence Report had not been completed. Although evidence was provided that an Internal Investigation was conducted by the Clinical Nurse Manager on 7/25/14, the opportunity to further analyze the event to identify causes and identify opportunities for further improvement did not occur.