BRATTLEBORO—The Brattleboro Retreat has changed its admission and discharge practices after a May incident in which a patient committed suicide within 24 hours of leaving the psychiatric facility.
The suicide prompted a state probe in which investigators identified two regulatory violations: Officials say Retreat staff members failed to inform a guardian and a caseworker of the patient’s impending discharge, and they also failed to properly assess the patient’s discharge plan.
But even before the state’s investigation was conducted in July, Retreat administrators say they had launched their own internal review and made procedural changes aimed at addressing the problem.
The result is that the Retreat doesn’t face further sanction at this point, Retreat leaders and state officials confirmed.
“We are deeply saddened by the death of the person described in the [state] report and extend our ongoing sympathy to all who have been impacted by this loss,” Retreat administrators said in a prepared statement. “Our goal is to ensure that each patient’s return to the community is safe and successful.”
Addressing regulatory issues
The Retreat has had multiple regulatory issues that at times jeopardized the facility’s Medicare and Medicaid funding. But the facility recently has experienced a run of good news on that front.
In November, a survey by state and federal regulators found the Retreat to be in full compliance. The following month, the federal Centers for Medicare and Medicaid Services released the Retreat from a “systems improvement” plan and lauded “the impressive progress and strides the hospital has made over the past year.”
The newly disclosed investigation by the state Division of Licensing and Protection found “standard-level deficiencies,” which are considered less severe than the “condition-level deficiencies” the Retreat had dealt with previously.
Standard-level deficiencies don’t jeopardize the Retreat’s funding, said Suzanne Leavitt, the Division of Licensing and Protection’s assistant director of survey and certification. The state also doesn’t generally conduct follow-up visits for standard-level findings, she added.
Nevertheless, documents from the state’s investigation offer a detailed look at the treatment and discharge of a person identified only as Patient No. 3, who was admitted voluntarily to the Retreat on May 25 due to “increased mood instability and thoughts of suicide.”
The patient, who had sought hospital care after undergoing an emergency crisis screening, had a history of attempted suicide and intentional overdose, according to the state report. The patient also had auditory hallucinations and was “disorganized and paranoid,” officials wrote.
The patient had been assigned a “public guardian” and also had a case manager with Pathways Vermont, an organization that provides support and housing assistance for those with mental-health issues.
On May 27, the Retreat developed a seven-day treatment plan for the patient. One of the goals was to “ensure adequate support after discharge,” and a social worker was directed to “collaborate with Pathways case manager and guardian and provide additional recommendations as needed.”
‘No red flags’
A social worker’s initial conversation with the patient’s guardian “confirmed no formal plans for discharge had been created,” documents say. Also, because it was Memorial Day weekend, officials said any further plans for discharging the patient were supposed to be reviewed with the guardian on May 31 — the day after the holiday.
But that changed May 28, when the patient requested a discharge. He told a nurse that “he could handle things on the outside” and he “wanted to go home to clean his room.”
A consultation with an on-call doctor followed. The nurse saw “no red flags,” documents say, though it was noted that the patient was still feeling depressed and continued to make paranoid statements.
The doctor found the patient to be “calm and in good behavioral control.” The physician’s final assessment said: “Distress, paranoia and cognitive disorganization have improved. S/he is not willing to remain in the inpatient context for further stabilization and does not meet criteria for involuntary treatment.”
State officials say the doctor’s report included no acknowledgement that the patient was receiving guardianship services.
The patient met with a Retreat social worker that afternoon. The social worker observed anxiety and delusions and said the patient, while planning to continue methadone treatment, was “unsure about whether or not s/he will see a therapist or consider other aftercare options such as psychotherapy and peer support.”
But the social worker, who told investigators a nurse said the patient “was good to go,” also noted that the patient wanted to leave and didn’t want to talk.
Neither the nurse nor the social worker reviewed the patient’s treatment plan, state investigators found. Also, neither the patient’s guardian nor the Pathways Vermont case manager was consulted prior to discharge.
The nurse wasn’t sure where to find a treatment plan or court-ordered guardianship documents within the patient’s medical records, state officials wrote. The nurse reported that, had she or he been aware of that information, it “may have changed [the] discharge plans.”
The social worker noted “pressure by the patient to get out” and took responsibility for failing to review the patient’s record, but also said she or he had assumed that the nurse or on-call doctor had assessed the patient’s safety.
Within 24 hours of discharge from the Retreat, the patient took their own life.
The state’s review doesn’t draw a direct line between the breakdown in communication at the Retreat and the subsequent suicide. But officials make clear that a critical link was missing in the patient’s discharge process.
“The lack of notification prior to discharge prevented the guardian [from] collaborating with hospital staff and the patient in making an informed decision regarding a safe discharge and also ensuring housing and community support availability,” state officials wrote.
In response to the state’s investigation and findings, Retreat administrators said they have taken steps “to improve certain aspects of our admission and discharge processes, which are now standard in cases involving voluntary admission and discharge.”
“These steps were subsequently accepted by the state as part of an action plan that was submitted to regulators following their on-site review in July,” the Retreat’s statement said.
State documents provide some details of those changes. For example, a task force convened at the Retreat in June to “identify communication gaps” and to recommend ways to ensure that legal documents such as guardianship paperwork won’t be overlooked.
That led to the creation of a special folder for legal documents within a patient’s electronic medical record. Staff members have been educated on the folder and its contents, documents say, and a review is ongoing to ensure the documents are being filed correctly.
The Retreat also has formulated a checklist of “the interventions needed for an unplanned discharge.”
As with the folder for legal documents, staff has been educated about the checklist, and a review is ongoing.