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New rules

With half of the Brattleboro Retreat’s funding for child, adolescent, and adult patient-care services at stake, federal policy has forced the psychiatric hospital to adopt strict new rules about calling police to subdue violent patients

BRATTLEBORO—Two years after the Brattleboro Retreat opened its doors to patients displaced from the Vermont State Hospital, the 179-year-old psychiatric hospital continues to wrestle with patient rights and staff safety.

During an unannounced on-site complaint investigation on July 15 and 16, the Centers for Medicare and Medicaid Services (CMS) determined that the Retreat, which specializes in mental health and addiction care, violated CMS polices.


CMS has identified areas where the Retreat has not met the center’s conditions of participation on at least four occasions this year.

In this case, the condition involves the circumstances under which Retreat staff have called the Brattleboro police to assist with uncooperative patients. In response, the Retreat has outlined changes to its security policies in a letter to employees for in-patient units — namely, the hospital’s “Use of Police Response to Safety Emergencies” policy, which has been eliminated.

Some staff members described feeling caught in a pinball machine, bouncing between attempting to care for patients, complying with state and CMS policy, and protecting their personal safety.

According to a CMS Statement of Deficiencies and Plan of Correction report, actions by staff and law enforcement led to the tasing and handcuffing of a patient. The use of weapons and law enforcement in care settings is against CMS policy.

The quandary, however, is that the incident was preceded by the patient verbally threatening other patients, throwing a chair, and hitting a mental health worker (MHW) in the head repeatedly.

CMS agreed to allow the hospital time until Aug. 29 to transition to new safety regulations that no longer include calling law enforcement to the units.

Ultimate goal

The Retreat’s ultimate goal is to “eliminate law enforcement’s involvement,” said Peter Albert, senior vice president of government relations and managed service organization.

Some of these patients have been involuntarily committed through a court order and refuse treatment, said Albert. Some are violent to themselves and others.

“We’ve been working on this for the last two years,” Albert said. “No one has a quick answer on that.”

The hospital is looking at the issue systematically and feels it’s the system that is broken, said Albert.

He pointed to the length of time involved in the legal process to medicate a patient against his or her will. That process can take up to 80 days, during which time a patient goes untreated.

To receive Medicare funding, the Retreat must be certified by CMS.

If CMS pulls its certification, as it did with the Vermont State Hospital in Waterbury over 10 years ago, then the hospital loses a chunk of its funding. The state contracts with the Retreat for about $8 million a year to treat patients who are wards of the state.

Escalating behavior

During its most recent investigation, CMS determined that on July 3, the Retreat violated the standards for patient rights regarding restraints and seclusion. The hospital also relinquished control of the situation to law enforcement.

CMS noted that although Retreat staff possess Crisis Prevention Institute training (CPI) to help de-escalate patients’ behavior, staff “chose to request police assistance with the administration of the emergency medication.”

In its report, CMS investigators stated that Patient #1 had a diagnosis of schizophrenia, disruptive mood dysregulation disorder, and a recent history of a violent assault.

Other patients asked staff members to intervene when Patient #1’s behavior escalated.

The attending psychiatrist initially ordered Patient #1 to be removed from the general population to seclusion but later reversed the decision, keeping Patient #1 with other patients. Patient #1 would view seclusion — placement on the Adult Low Stimulation Unit (ALSA) — as “punitive,” said the report.

The next morning, Patient #1 attempted to pour coffee on the head of a mental health worker, who pushed the cup away.

The worker later told CMS during the agency’s July 16 investigation that Patient #1 “came in with repetitive blows, pummeling my head...his/her arms were coming in from both sides. There was no escape...thought I would lose consciousness.”

After Patient #1 refused the Thorazine, the supervisor for Security Services and charge nurse elected to contact Brattleboro Police to help administer the medication.

Patient #1 then lunged at two Brattleboro police officers and was tased by an officer and handcuffed, according to the report.

“We are not equipped to handle a patient this size and strength,” the security supervisor told CMS.

A letter to staff

Two years ago, when Tropical Storm Irene flooded the Vermont State Hospital (VSH) in Waterbury, the Retreat opened its doors during the storm to displaced patients and VSH staff.

Since that night, the hospital has become one of four in the state providing treatment for state patients.

Last year, the Retreat received $5.3 million in state funds to upgrade its facility and create a 14-bed acute care unit. The hospital routinely cares for more than 14 state patients.

But caring for patients with a higher level of acuity has come with challenges, like more scrutiny by CMS, the state, and the press, and like caring for those who sometimes demonstrate violence toward staff and other patients.

The Aug. 2 letter, “Action Steps to Assure Patient and Employee Safety,” was signed by Retreat President and CEO Rob Simpson.

“This month CMS found the Retreat to be in non-compliance with federal regulations and conditions of participation [...] by using police to assist in patient care,” Simpson wrote.

The Retreat has met with the Brattleboro Police Department and has confirmed that officers will “not remove a patient from a psychiatric unit for assaultive behavior when that patient has a diagnosed mental illness.”

“This does not mean that charges for that assault may not be filed,” continued Simpson’s letter.

Brattleboro police assisted Retreat staff with patients four times this year, according to Simpson. He described calling the police to inpatient units as “infrequent.”

According to the letter, other hospitals are moving toward not calling law enforcement unless a patient is to be arrested or otherwise removed from the facility.

The state recently passed a law that affirms that when dealing with someone with a mental health diagnosis it is difficult to determine if that person is responsible for his or her actions, said Albert.

Deputy State’s Attorney David Gartenstein has told The Commons last year that the legal criteria to prosecute someone undergoing treatment for mental illness is a high bar to reach.

A catch-22?

Simpson’s letter to staff has raised questions among Retreat employees who spoke with The Commons on the condition of anonymity.

The issue of staff safety rose to the surface last year during union contract negotiations.

After interviews with staff last year, The Commons investigated allegations that violence toward staff had increased [“Records show increase in Retreat assaults,” Dec. 12]. Police reports and workers’ compensation data confirmed those assertions.

In speaking about the new policies, one employee pointed out that if staff can’t call police, the Retreat could simply look better on paper while nothing happens to increase staff safety.

Other employees felt the hospital had effectively nixed their ability, and right, to report an assault.

Multiple employees questioned the role of the state in providing adequate psychiatric care within prisons for severely mentally ill patients who are also violent.

The employees who spoke with The Commons offered the consensus that the state’s mental-health system is broken. Employees also pointed to long waits for administering involuntary emergency medications to violent patients and the limited number of facilities providing transitional care for patients after they leave in-patient treatment like the Retreat.

Another employee expressed frustration with CMS. While the agency’s polices try to create a safe environment for patients, said the employee, ticking all of CMS’s boxes diverts management’s attention and overloads direct-care staff with rules and regulations.

New policy

“The police may only be called onto an inpatient unit when the hospital believes that a crime has been committed and the patient will be removed from the hospital,” stated Simpson’s letter.

The CEO added that Retreat officials have met with town police and union leadership to discuss the policy changes.

The Retreat also instructed employees that they can no longer use police “as a supplement to a safety emergency on an impatient unit.”

According to CMS’s guidelines, patients have the right to receive care in a safe environment and be free from restraint or seclusion.

The regulations seek to protect patients from restraint and seclusion imposed through coercion and discipline, or for convenience or retaliation by staff.

Instead, CMS allows patients to be restrained or placed in seclusion only to protect the immediate physical safety of patients, staff, or other people.

Also, CMS considers the use of weapons — Tasers, nightsticks, guns, handcuffs, pepper spray — as the purview of law enforcement and not appropriate in a hospital setting.

“If a weapon is used by security or law enforcement personnel on a person in a hospital (patient, staff, or visitor) to protect people or hospital property from harm, we would expect the situation to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement,” states CMS in its regulations.

The hospital will instead employ additional security officers to assist unit staff. The Retreat has started a job search for two additional security officers, one each for day and evening shifts, to provide “direct coverage on our most challenging units,” wrote Simpson.

The in-house security staff will serve as backup support to the clinical staff and be trained in the same clinical process of de-escalating patients. But security staff will assist only at the direction of clinical staff, said Albert.

Calls to police must be approved by the nursing supervisor and administrator on call.

“This will clearly be an extremely rare occurrence given the understanding in Vermont by law enforcement and the state’s attorneys that patients in psychiatric hospitals should remain in hospitals for treatment of their illnesses and not be placed in prison or community cells,” Simpson’s letter noted.

The Retreat will also increase its training on best practices for managing violence, increase staff participation in “code green” safety drills, start including “violence plans” as part of patients’ treatment plans, and produce debriefing reports to senior Triad leaders of each unit (the unit chief/lead physician, the clinical nurse manager, and the social work supervisor) on all incidences of violence to help staff debrief after incidents.

Training for the new approach

Staff will undergo ongoing training in CMS’s patient rights on all units, root-cause analysis of violent incidents, and clinical case conferences.

The goal with this training is to help all staff feel they have the tools to be in control of difficult situations and to feel safe, said Albert.

The focus of the training and skills is to help staff identify patients’ issues early so they don’t escalate in the first place, he added.

“The sooner we identify an issue and address it, the less the patient escalates and [the less] staff needs to call for back up,” said Albert.

Albert added that staff should aim to keep hands off patients with mental illnesses, who, he noted, are people dealing with deep traumas and who do not perceive the world in the same ways that other people might.

On July 31, Simpson approved a new position for a full-time CPI instructor/program coordinator. This person will oversee CPI training and will monitor monthly drills that let staff train and practice for emergencies, including scenarios involving combative people.

“The past two years have been among the most challenging in the Retreat’s 179-year history due in large part to our willingness to provide care for some of the most seriously ill patients in Vermont,” wrote Simpson.

“At all levels of the organization, employees have demonstrated skill and commitment to this extremely challenging work on behalf of people who come to us experiencing profound pain and suffering,” he continued.

Simpson added, “The State of Vermont is attempting to build a more progressive, fair, flexible, and effective mental health system for our state and we have engaged as partners along with other hospitals and community mental health agencies.”

Parallel processes

As the Retreat has grappled with the changes sparked by patients with new needs, the hospital administration has engaged in constant communication with CMS at the local, regional, and national levels, Albert said.

The Retreat had believed it had interpreted CMS’s policy correctly, said Albert. But subsequent phone calls with the agency proved that interpretation to be mistaken.

The Retreat’s staff are good and will continue to get better, said Albert, noting that staff “have really done a remarkable job” with training, revising policy, and developing new skills.

The hospital seeks to produce well-trained, experienced staff who feel competent to respond to patients with a higher level of acuity, said Albert.

If staff are still feeling unsafe, then “that’s important to know,” said Albert. It’s the Retreat’s job to “listen when staff and patients say they do not feel safe” and address the situation.

In addition to meeting its Aug. 29 deadline for implementing policy changes around the use of law enforcement, CMS has given the Retreat until Oct. 30 to meet the Plans of Corrections to protect the hospital’s overall CMS certification. The original deadline had been Aug. 15.

CMS has given the Retreat two deadline extentions as the hospital works to protect its CMS certification.

CMS granted the two extensions because the facility’s submitted Plans of Corrections were not acceptable.

Changing the state’s mental-health system is a “parallel process,” Albert said.

The Retreat has faced its own shortcomings that it must own and correct, Albert said; meanwhile, everyone involved in mental-health issues in the state must also learn from and improve the current system.

“This is our opportunity” said Albert, to address systematic issues in the state’s mental health system.

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Originally published in The Commons issue #220 (Wednesday, September 11, 2013).

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