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.

An unannounced, onsite complaint survey was conducted on 12/21/20 through 12/22/20 by the Division of Licensing and Protection. The following regulatory violation was identified:

482.23(b)(3) Condition of Participation: Nursing Services: Standard Requirement A-0395.

This requirement was NOT MET as evidenced by:

Based on record review, policy review and interviews the facility failed to ensure 1 patient [ #1] of 10 sampled patients was appropriately assessed for pain after an injury. The patient was not transferred to the hospital for further evaluation in a timely manner and in accordance with accepted standards of nursing practice.

Findings include:

Per record review, information on the client profile shows that Patient # 1 was admitted to an adult unit at the Brattleboro Retreat from 06/08/20 through 12/11/20 for an involuntary admission. S/he has diagnoses including Psychotic Disorder and Bipolar Affective Disorder. This patient has had multiple admissions and a documented risk for harming others.

The incident occurred on 12/10/20. The Certificate of Need (CON), which is a form used to document required elements as defined by hospital policy and regulations for Restraint and/or Seclusion, indicates a physical hold restraint occurred with a start time of 03:35 PM and an end time of 03:40 PM. It was noted that Patient #1 ceased to stand, dropping their body to the floor. Staff and patient collapsed to the floor. Patient #1 landed on their right side.

Per record review and interview on 12/21/20 at 03:30 PM with staff A Registered Nurse (RN) assigned to Patient #1, during shift change report, the patient came toward him/her after taking a shower. S/he was redirected to go back to the Adult Low Stimulation Area (ALSA) 2 times where the patient's bed was. The RN did not know what the patient would do. S/he would not follow direction and had his/her own agenda. Staff A took the patient's arm, turned him/her around to escort him/her back to his/her room. A Mental Health Worker assisted on the other arm. The patient was holding linens and an electric razor in his/her left arm. Staff A tried to remove the items from the patient's hand at the same time restraining the patient against the wall. The patient collapsed on the floor along with the two staff. The patient was screaming threats that s/he would "hire someone to kill me." According to Staff A, the patient yelled "my knee hurts". Staff A left to get a physician restraint and medication order. When S/he returned, the patient had already been assisted to the restraint chair. An intramuscular (IM) injection of Benadryl 50 mg and Haldol 10 mg was given in the patient's right dorsal gluteal.

Per interview on 12/21/20 at 4:00 PM with Staff B (RN) who took over as charge nurse on the 3-11pm shift, but was not the patient's assigned nurse, stated there was a Code Green during report (a Code Green is announced over the hospital intercom in the event that there is risk of danger from a patient's behavior). Staff responded to the area of the hospital where the patient incident was occurring. Staff B entered the room where the patient had already been placed in the restraint chair. Staff B asked the patient if s/he was in pain. The patient reported "I heard a pop" but was not in pain at the time and proceeded to say, "don't worry about it". The primary nurse Staff C (RN) took over assigned care of Patient #1.

Interview on 12/22/20 at 03:30 PM with Staff C revealed that S/he approached the patient while in the restraint chair. The patient was extremely agitated and verbally threatened to kill Staff A. The patient had not shown signs of physical distress. Staff C states "In my opinion, I was not concerned about any status of physical injuries". A face to face assessment took place around 4:45 PM. Staff C states "we wheeled the chair into his/her room as to not to bare additional weight." Staff C also stated "in my eyes if you have a truly broken bone you should not be able to bare any weight, there should be discoloration at the site." Staff C also stated "In my mind it was a highly inflamed muscle on top of old age, and I viewed it as a possible strain due to the lack of discoloration." Staff C notified the nurse practitioner at 04:20 PM to come do an assessment. Staff C stated during the interview "This is the part where we should always, trust our patients, well (pause) what the patient reports as pain is the patient's pain level, and that is a constant threat in nursing." Staff C also indicated that one of the reasons that this incident and the time scale lasted as long as it did, "was not (pause) you know restraint, pain, call the doctor within two hours." Staff C indicated that unlike nursing textbooks this was due to the patient's, for lack of better understanding, "boy who cried wolf."

Interview on 12/22/20 at 01:18 PM with Staff D (Clinical Nurse Manager) indicates the nurse assigned was unable to assess the patient as the patient was not allowing assessment. The patient was wheeled in the chair to his room because he was complaining of pain. When the patient was assisted to his/her bed from chair, S/he did have pain.

A nursing progress note dated 12/10/20 indicates that the patient stated, "When I'm out of this place you won't be safe". There were also other verbal threats. The patient was not showing signs of pain until just before transferring out of the chair. Patient #1 stated, "My [f***g] hip feels broken".

Interview on 12/22/20 at 11:15 AM with Staff E (APRN) indicates that the nurse alerted her/him a little before 06:00 PM that Patient #1 was complaining of pain at the point of the injection site. The nurse asked for an assessment to be done before the practitioner's end of shift. The practitioner had to see another patient first and then assessed Patient #1 at 8:00 PM. The patient stated, "I am in so much pain". S/he hollered, "They broke my hip".

Per Physician Inpatient Progress Note dated 12/10/20, Patient #1 reported that s/he heard a "pop and felt severe pain instantly to the right lateral hip". S/he told staff their hip was hurting, and it felt broken. According to the note, upon assessment the patient was tearful when in extreme pain and could not tolerate the pain in the right leg when asked to roll over. A hospital transfer order was placed. Per Event incident/accident log, Patient #1 was transferred to the hospital at 09:28 PM.


Interviews and record review reveal that Patient #1 sustained a right hip injury at the time they were placed in a restraint hold. Patient #1 landed on their right side. Per Staff A, the patient yelled "my knee hurts" at 03:45 PM. The patient was assisted to the emergency restraint chair and released at 04:48 PM. Involuntary medication Haldol 10 mg and Benadryl 50 mg was given intramuscularly to the right dorsal gluteal muscle at 03:45PM while still in the restraint chair. The patient was assessed at 04:20PM by Staff C at which time the patient stated, "my [f***g] hip feels broken". The patient was assessed again at 04:45 by Staff C who describes that the patient began to "slowly moan with increasing volume." The practitioner was notified at approximately 06:00 PM and the patient was assessed at 08:00 PM. The patient was transferred to the hospital at 09:28 PM. Per a radiology report dated 12/10/20, the patient sustained a comminuted transcervical fracture of the right femoral neck. It was approximately 5 1/2 hours from the time the injury occurred to the time the patient was transferred to the hospital.