BRATTLEBORO — Vermont state investigators have cited the Brattleboro Retreat for a violation after a patient broke a hip in a scuffle with staff in December — and the patient had to wait five hours to be taken to the hospital.
The state Division of Licensing and Protection outlined its findings in a letter to the Retreat in January, stating that the delay in helping the patient get medical care violated standards for “nursing services.”
But mental health advocates argued that the facility should have been cited more aggressively, saying the incident is part of a broader pattern of patient safety concerns at the Brattleboro Retreat.
“What happened with a broken hip is a symptom of the larger problem in Vermont, which is a dehumanization of people in mental illness,” said Wilda White, who runs MadFreedom, a mental health advocacy organization. She said she’s planning activism around the issue but declined to say what that would entail.
Vermont Rep. Anne Donahue, R-Northfield, said she forwarded the findings to her fellow members of the House Committee on Health Care for review.
“It’s a stunning report,” she said. Donahue called for greater accountability, both for the Retreat and for the state, which she contended isn’t using its enforcement authority aggressively enough.
According to the investigation, a patient, who had been hospitalized involuntarily at the Retreat since June, refused to go back to an isolation room after taking a shower on the afternoon of Dec. 10. At 3:30 p.m., when staff members tried to escort the person back to the room and take the individual’s towel and razor, the patient resisted, yelling at and threatening staff, according to the documents.
The patient, who was not identified in the report, fell to the ground, bringing staff down with them. The patient immediately yelled of knee pain, staff members said. Retreat workers put the patient in a restraint chair and injected the patient with medication involuntarily.
Staff reported the patient was initially less concerned about the pain, but by 4:20 p.m., complained that “my f---ing hip feels broken,” according to the report.
One staff member told investigators she expected it was a strain, due, in part, to the patient’s “old age.” Another worker compared the patient to the “boy that cried wolf.”
After the patient’s moans grew louder, staff called for a doctor at 6 p.m. A doctor assessed the person two hours later and at 9:28 p.m., 5½ hours after the fall, the patient arrived at the hospital. An X-ray showed a broken hip.
According to Retreat spokesman Konstantin von Krusenstiern, the facility immediately reviewed the incident and made changes.
“Immediately following an incident on Dec. 10 involving a patient with complex psychiatric issues, we recognized that this individual’s medical assessment took too long to happen,” von Krusenstiern said in an email to VTDigger.
Retreat staff reported the incident to the state, interviewed staff who were involved, reviewed the findings and created a plan of correction.
“Anytime a patient is injured, we consider that a failure,” von Krusenstiern said.
‘Not a pattern’
After receiving a complaint, the Vermont Division of Licensing and Protection showed up unannounced at the Retreat to investigate on Dec. 22.
Investigators reviewed the incident, as well as nine others to compare, said Suzanne Leavitt, state survey director for the division. Ultimately Leavitt and her staff cited the Retreat for the long delay in medical care — but did not find evidence of similar lapses.
“We came up with a deficiency for one instance for one person,” Leavitt said. “We identified that they don’t have a pattern of unaddressed conditions.”
The state did not consider past issues that had already been corrected.
That meant the Retreat got a lesser violation — for “nursing services” — but did not have to file a plan for corrections to the state or submit to follow-up investigations.
Leavitt would not say why the broken hip itself was not a violation. The federal Centers for Medicare and Medicaid Services — not the state — sets the standards they are to investigate, she noted.
When a patient ends up with a broken hip and has to wait hours to go to a hospital, “it is a big deal,” Leavitt said. “Just because we don’t cite this at a high level doesn’t mean that it’s not a big deal. If they’ve corrected their action, we don’t cite them for it. Our job is not to be punitive.”
The Retreat had revised policies and procedures for instances when a patient reports pain, according to a written response to the complaint sent to the state. Staff would be required to attend implicit bias training and to participate in “education” about patients who have medical complaints.
“We are committed to providing our patients and staff with the safest possible environment of care and to ensuring our patients receive the care they need,” von Krusenstiern said.
Mental health advocates said the report highlights the need for more rigorous review of restraint and the interactions that led up to the incident.
The patient was restrained, according to the report, because the nurse “did not know what the patient would do. S/he would not follow direction and had his/her own agenda.”
“Restraint routinely happens not when people are actually causing harm to others but when people are noncompliant,” said Malaika Puffer, a psychiatric survivor and mental health worker who serves on an advisory committee for the state Department of Mental Health.
Restraint is meant to be used when a patient is a danger to herself or others.
“There is no danger described here,” Puffer said.
The situation pointed to a larger pattern at the Retreat, said White, the mental health advocate.
The facility has reported more frequent use of restraints, isolation and involuntary medication than other Vermont psychiatric facilities, with an increase since the start of the pandemic.
Incidents such as the one at the Retreat are all too commonplace, White said.
“It’s egregious, and it happens all the time,” she said.