The new state Vermont Psychiatric Care Hospital in Berlin violated federal standards of patient care after a supervising nurse repeatedly and intentionally took actions that upset a patient with “severe” obsessive compulsive disorder, documents show.
A Feb. 4 survey by the Vermont Division of Licensing and Protection found that the nurse directed staff to intentionally ignore the patient – a directive in conflict with the patient’s treatment plan – while “taunting” the patient and then intentionally agitated the patient until the patient was “angry, yelling and hysterical.”
The nurse violated a federal standard that says patients have the right “to be free from all forms of abuse or harassment,” the report says.
The nurse told inspectors she was using tactics to de-escalate a tense situation. The inspection found that the hospital was not at fault and “the findings in this survey resulted from deficiencies in job performance, rather than from systemic processes and factors that require correction.”
The problems highlight staffing issues that have dogged the new facility since it opened last year. Officials won’t give any information about the case or the nurse, citing the state’s policy to keep personnel matters confidential.
‘Planned Ignoring’
Patient #2, as the report calls the patient, had trouble at the hospital after being admitted on Nov. 19, 2014, the report says.
“During Patient #2’s hospitalization, certain ‘triggers’ and ‘fears’ have resulted in maladaptive behaviors which have impacted the patient’s ability to sustain and maintain compliance with hospital rules, medication administration, activities of daily living and food consumption,” the report said.
The mental illness made it difficult for the patient to go about daily life and challenged care providers who were trying to treat the illness.
The nurse directed staff to intentionally ignore the patient- a directive in conflict with the patient's treatment plan - while "taunting" the patient.
On Jan. 2, the patient’s physician wrote about the patient’s treatment that “[w]e all have difficulties trying to find a consistent and recovery centered approach and everybody wants a magic formula.”
The staff developed “various approaches,” the report says, to help Patient #2 and staff manage stressors.
One weekend in January, the evening charge nurse changed the plan.
The report says that “on the evening of 1/3/15 and 1/4/15 the evening charge nurse decided s/he would manage Patient #2’s behaviors by directing staff to play a role in ‘planned ignoring’ (behavior management strategy used to reduce attention seeking behaviors).”
The report says staff were told to ignore the patient’s requests “to include special accommodations previously provided to assist with the patient’s significant OCD,” with no apparent consultation with any doctors involved in the patient’s treatment.
Staff reportedly described the patient as “visibly upset, crying and pleading for assistance throughout the evening,” the report said.
The nurse who issued the directive didn’t ignore the patient, though, according to the report.
“Witnesses described the charge nurse as ‘taunting’ Patient #2 by repeatedly asking the patient to play a horseshoe game,” the report says. “The patient continuously refused, saying ‘No’, expressing increased agitated and emotional frustrating with each repeated request made by the charge nurse over and over again.”
Staff reportedly described the patient as "visibly upset, crying and pleading for assistance throughout the evening," the report said.
The psychologist treating Patient #2 wasn’t on board with the "planned ignoring," telling inspectors that it was “never part of the plan” and that it was “inappropriate and not used in psychiatry for patients with OCD.”
That Monday, Jan. 5, the patient went to a nurse’s station in the hospital and asked to speak to the supervisor on staff “regarding the escalating anxiety s/he was experiencing, attempting to seek help from staff outside the unit.”
But the nurse, according to the report, didn’t go to a supervisor right away.
“At that point the charge nurse opened the door to the nurses [sic] station and Patient #2 grabbed the door and slammed it shut,” the report says. “Per witness accounts, the charge nurse continued to reopen the door to the nurses station approximately 5-7 times, each time smiling and laughing at the patient, inciting and provoking the patient, who then slammed the door.”
A staff member later recalled to investigators that the patient was “angry, yelling and hysterical.”
The nurse claimed she was using the door as a “distraction” in an effort to de-escalate the situation, though “this mode of ‘de-escalating’ for Patient #2’s behaviors was not part of the treatment/nursing plan.”
The psychologist treating Patient #2 wasn't on board with the "planned ignoring," telling inspectors that it was "never part of the plan" and that it was "inappropriate and not used in psychiatry for patients with OCD."
All of these decisions seem to have been made unilaterally by the nurse. The psychologist treating the patient noted that same day that the patient said “her/his anxiety level has been ‘through the roof’ the past several days because s/he feels that most staff don’t understand her/him,” the report says, noting that the anxiety was so severe that the patient “thought about killing herself.”
A psychologist interviewed by investigators said that nurses are not supposed to determine which techniques will best manage patient behaviors.
‘Abused And Neglected’
The state has systems in place to ensure that people with a record of harming vulnerable adults aren’t put in a position to do so again.
Within the Division of Licensing and Protection is Adult Protective Services, a unit charged with investigating reports of abuse, neglect and exploitation of elderly or disabled adults. When allegations are substantiated, the person who carried out the abuse or neglect is generally placed on a list known as the “APS registry.” The registry isn’t public, but institutions responsible for caring for vulnerable adults in Vermont are able to check potential hires against the registry to ensure the person doesn’t have a history of abusing vulnerable adults.
According to Suzanne Leavitt, the assistant director of the Division of Licensing and Protection, health care facilities would be cited if inspectors found that they employed someone on the APS registry.
The state has systems in place to ensure that people with a record of harming vulnerable adults aren't put in a position to do so again. Documents show the nurse was immediately placed on administrative leave once the allegations were substantiated.
In this case, Adult Protective Services notified officials at the psychiatric hospital on March 11 that the allegations against the nurse of abuse and neglect of Patient #2 had been substantiated. Documents show the nurse was immediately placed on administrative leave. The finding was also reported to the Vermont State Board of Nursing. However the Division of Licensing and Protection documents don’t name the nurse or the patient. Officials at the hospital, the Department of Mental Health (which runs the hospital) and the Department of Licensing and Protection all refused to name or comment on the status of the nurse.
As of May 15, when Leavitt approved the hospital’s plan of correction for issues found in the Feb. 4 inspection, the nurse remained on administrative leave.
Nursing Shortage
Nurse staffing has been a problem within the state’s mental health system since shortly after Tropical Storm Irene hit the state in 2011. The storm flooded Waterbury and forced the state hospital there to close.
“After a number of months, there was a Reduction In Force (RIF),” says Vermont Psychiatric Care Hospital CEO Jeff Rothenberg. “And all the positions that were in the PN1 – Psychiatric Nurse 1 – were eliminated. Psychiatric Nurse 1 is that classification for nurses without any experience right out of school.”
After that, only more experienced nurses remained, and they had to be replaced by experienced nurses who fall into the Psychiatric Nurse 2 category. That requirement is being removed soon but it is one reason for the new hospital’s staffing shortages, Rothenberg said.
Besides a lack of qualified nurses in the state, Vermont Psychiatric Care Hospital CEO Jeff Rothenberg says the salaries the psychiatric hospital offers are a major reason the hospital has trouble recruiting new nurses.
“All the people in that position had been RIFed, and then when we opened the new hospital and opened up new positions, we have not opened up any PN1 positions,” he said. “But that’s something that we’re going to start advertising for and then having a more lengthy orientation process, like a three to six month orientation process for brand new nursing students,” he said.
Besides a lack of qualified nurses in the state, Rothenberg said the salaries the psychiatric hospital offers are a major reason the hospital has trouble recruiting new nurses.
“The primary reason we hear when we have nurses apply and inquire about it is salary,” he said.
An Agency of Human Services workgroup is looking into nursing salaries across the agency, Rothenberg said, and is expected to deliver a report with recommendations related to nursing salaries this summer, “so we’re hopeful that there’ll be some progress there.”
