Brattleboro hospital cited with violations in emergency department
BRATTLEBORO — Following an un-announced visit on March 24, Brattleboro Memorial Hospital was found to be in non-compliance with a pair of federal regulations.
Based on record reviews and interviews, in a pair of incidents at the hospital, BMH personnel failed to "provide sufficient interventions to assure each patient's rights are protected," stated the survey documents released by the Vermont Division of Licensing and Protection. The incident was related to patients who were admitted to the hospital for a mental health crisis.
According to the survey results, the hospital failed to assure that patients would receive care in a safe setting; that it failed to assure the patient's rights by relinquishing care to law enforcement; failed to discontinue the use of restraints at the earliest possible time; failed to ensure the restraints were used to keep the patient and others safe; and failed "to initiate new orders for the application of restraints and the administration of emergency medication."
According to the survey results, when emergency department staff called the Brattleboro Police Department for assistance in one of the reviewed incidents, unnecessary force was used "to immobilize the patient to include manual restraints and handcuffs."
"(T)he hospital failed to effectively meet the needs of a patient with a psychiatric emergency condition by demonstrating a failure to provide appropriate health care intervention and behavioral management and utilizing law enforcement to augment staff with patient care," stated the report.
The federal Centers for Medicare and Medicaid Services delegates these types of investigations to the state. If the violations are not addressed, a facility could lose its Medicare and Medicaid funding.
BMH CEO Steve Gordon and Chief Medical Officer Kathleen McGraw said a corrective action plan has been put in place and on Monday and Tuesday of this week, investigators from DLP visited the hospital.
"They have given their approval for the corrective action plan and verified we have implemented the steps contained," said Gordon.
"We are in compliance with all of it," added McGraw.
Gordon said DLP initiated the audit after receiving complaints about the care of a specific patient, but added that BMH welcomes these types of audits. "We see them as an opportunity to improve patient care. Our approach has always been, what can we learn and what can we put in place to improve patient care and insure the safety of our own staff."
The BMH emergency department is often used to care for patients when there are no beds available at psychiatric facilities such as the Brattleboro Retreat. If there is an incident requiring a police response, the Brattleboro Police Department is called in to assist, which can result in a response that is more suited to criminals rather than to someone with mental illness.
"There's a breakdown in the system," Brattleboro Police Chief Mike Fitzgerald told VTDigger. "A person suffering from a mental health crisis doesn't belong in the ER. They belong in a mental health facility where they would get the care that they need."
McGraw noted that the results of the survey are an indicator of how the state and the nation allocates resources for those suffering from an acute mental health crisis. "We don't have adequate resources on a state-wide level to address all the patients who need care. It pushes the burden into emergency rooms and their staffs, who must care for them until a space is available at a psychiatric facility."
BMH works with Health Care and Rehabilitation Services of Vermont to care for those patients that arrive in the hospital, said McGraw. "HCRS evaluates whether a patient can be managed in a community setting or whether that patient needs more intensive care."
When Tropical Storm Irene wiped out the state's mental health facility in Waterbury, many hospitals responded to house its patients until more suitable facilities could be secured, forcing them to provide services they hadn't provided in the past. While hospitals were put on the spot to develop policies and procedures related to those patients, hospitals are now dealing with mental health issues related to the use of opioids.
"We have seen a dramatic increase in the acuity of mental health crises and psychology patients," said Gordon. "At some point in time there are not going to be enough beds and resources to take care of these patients, which contributes to length of stay in the ER."
Lt. Mark Anderson, of the Windham County Sheriff's Office, said while his department is not contracted by BMH to provide security, the Department of Mental Health contracts with the sheriff to provide supervision until a patient can be transferred to a psychiatric facility, which began following Tropical Storm Irene. "Since then, we have tried to treat every single mental health patient with care and compassion while insuring their own physical safety and those around them."
However, said Anderson, law enforcement personnel are being called upon to deal with people who while they might be acting out criminal behaviors, are not liable for their actions because of their mental health.
As part of Act 80, the Vermont Attorney General's Office was tasked in 2004 with developing a program to help law enforcement manage those having mental health issues.
Sheriff Keith Clark is one of the instructors who presents lessons learned and tactics to help officers with these types of incidents, said Anderson. "We have an active role in developing and coordinating with mental health professionals and hospitals to pioneer something that didn't exist prior to the closure of the state hospital. We need people on the same page, speaking the same language, hopefully to understand the abilities and limitations of each organization."
"Working with our partners, locally and statewide, we are working to provide the safest and most appropriate care with inadequate resources," said McGraw. "This is an ongoing process. Quality improvement is a long-term process."
Other details in the DLP report indicated hospital administrators had failed to implement "an ongoing program that show measurable improvements" in the identification and reduction of medical errors. In addition, the hospital failed to measure, analyze, and track "adverse patient events" and analyze their causes while implementing preventative measures and mechanisms.
"The hospital's governing body ... medical staff, and administrative officials are responsible for ensuring ... That clear expectations for safety are established. This standard is not met ..."
The hospital also failed to ensure an adequate number of nurses was available to provide care in the emergency department.
Bob Audette can be contacted at 802-254-2311, ext. 160.
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