Weiss EM, et al. Deadly restraint: a Hartford Courant investigative report.
Hartford Courant 1998; October 11 15.
October 15, 1998
Illustration: PHOTOS: (2 color), Rich Messina / The Hartford Courant
[NO Photos or Graphics are available for posting.
However, their Captions remain included.]
By ERIC M. WEISS
Part Five of a Five-Part Series published in The Hartford Courant,
beginning on October 11, 1998.
WITH STRONG LEADERSHIP,
THE CYCLE CAN BE BROKEN
Will Overton used to be called "The Enforcer.''
With 280 pounds of solid Tennessee muscle wrapped around a 6-foot-3 frame, the aide at the Harold W. Jordan Center was called in to help "shuffle'' patients -- slamming them to the ground face-down if they acted up or disobeyed. And the 30 mentally retarded and mentally ill patients -- people accused of murder, rape and other crimes -- often disobeyed. "I used to be a bad boy,'' said Robert Hall, a short, wiry patient with the energy of a wound rubber band. "I was shuffled about every day.''
Not anymore. Behind the Nashville center's locked gates and razor wire a radical turnaround has occurred in the last year. Shuffling is now forbidden, and staff has been increased and given intensive training.
Tennessee's example shows that, with strong leadership, the physical restraint of patients can be minimized -- indeed, nearly eliminated -- safely and without exorbitant cost.
"If we could do it here,'' said Frances Washburn, deputy superintendent of Clover Bottom Development Center, which includes the Jordan unit, "it can be done anywhere.''
But the routine and frequently dangerous use of restraints persists elsewhere, even though the solutions are often simple and straightforward: better training, stronger oversight, uniform standards and the collection and sharing of information.
Federal officials and health groups say they are working on it.
The U.S. Center for Mental Health Services has begun a five-state pilot program to collect restraint and seclusion data. The U.S. Department of Veterans Affairs is tracking deaths more closely.
The Joint Commission, the nation's leading hospital accreditation organization, has strengthened its guidelines on restraint and seclusion. And the American Medical Association has begun studying the use of restraints on children.
"Those steps sound pretty inadequate to me,'' said Dr. Joseph Woolston, medical director for children's psychiatric services at Yale-New Haven Hospital. "This sort of half-hearted patchwork approach will probably do more harm than good by giving an illusion that something is happening when it is not.''
So for now, it is left to individual hospitals to find their own way. Those committed to the task illustrate what can be done.
Riverview Hospital for Children and Youth, a state-run psychiatric hospital in Middletown, Conn., uses an intensive training program that emphasizes nonphysical intervention when a patient loses control.
"These situations are often chaotic and unpredictable, and without proper training, staffers are just winging it,'' says Linda Steiger, executive director of Wisconsin-based Crisis Prevention Institute.
CPI, a leading private training company, provides instruction to Riverview workers. The cost is minimal: $895 per person for a four-day program to teach a small number of designated staffers, who then instruct their peers.
Tighter procedures also emphasize that every restraint is a major step -- literally, a matter of life and death.
At Riverview, a staffer is required to constantly monitor anyone in mechanical restraints. That ensures a patient's vital signs remain strong, and provides an incentive to end the intervention as soon as the patient regains control.
At Tennessee's Jordan Center, patient treatment plans that include the use of restraint are, for the most part, rejected. And every use of emergency restraint is investigated and must be defended.
"When forced to go through the self-analysis and justifications, they solve it at a lower level the next time and without restraints,'' said Thomas J. Sullivan, who heads Tennessee's Division of Mental Retardation Services. "Of course, this requires staff to give up total control.''
Emergency restraints are so infrequent now that Sullivan gets an e-mail message every time they are used. He's gotten an average of just two to three e-mails per month since January.
Accountability means staffers share more information and learn from the mistakes of others. Techniques found to be dangerous, such as face-down floor holds and mouth coverings, have been outlawed in certain places as a result.
But tough lessons learned by individual hospitals typically aren't shared with facilities on the other side of town or 10 states away. Each hospital is left to reinvent procedures or learn the hard way -- through the death of a patient.
It doesn't have to be that way.
New York state has reduced restraint use and the number of related deaths by requiring the reporting of usage rates and by investigating all deaths.
After New York required all mental health facilities to say how often they use restraints -- and published the numbers -- the top three users revamped their policies and brought their numbers down.
When it came to deaths, the state used to allow each hospital to decide which ones were questionable enough to report. It was notified of 150 cases over three years. Once mandatory reporting of every death was instituted 20 years ago, the number of deaths requiring further investigation rose to 400 a year.
"When people have a choice in classifying deaths -- with one choice resulting in tremendous scrutiny, the other resulting in none, what do you think they're going to do?'' said Clarence Sundram, the former chairman of the independent New York agency that tracks and investigates deaths.
Accountability has produced results. Restraint-related deaths in the past five years have been cut nearly in half as compared with the preceding five years, New York state records show.
Nationwide accountability could accomplish the same.
"There needs to be some kind of state-by-state evaluation to gather comparative statistics and give an annual report to Congress,'' said Dr. E. Fuller Torrey, a prominent psychiatrist and author.
"Until you embarrass the individual states,'' Torrey said, "nothing will be done.''
The federal government has shown a willingness to intercede on this very issue -- in response to charges that the elderly were being abused.
When the U.S. Food and Drug Administration estimated in 1992 that more than 100 people annually were killed through the use of mechanical restraints in nursing homes, the agency tightened rules on their use.
"We also thought these cases were flukes,'' said the FDA's Carol Herman, "until we started digging.''
The FDA now considers lap and wheelchair belts, fabric body holders and restraint vests to be prescription devices. Manufacturers are subject to FDA inspections to ensure quality control.
Such steps, advocates say, have both reduced and improved the use of restraints. In the mental health field, strong and independent government oversight can weed out bad practices and bad facilities as well, they say.
"We can't do it alone,'' said Curtis L. Decker of the National Association of Protection and Advocacy Systems. "The only way to truly protect patients is through a large, comprehensive monitoring program.''
That means a system where government regulators, not the industry, are charged with oversight, he said. An internal patient grievance system would be bolstered by a well-funded network of independent advocates trained in death investigations.
More than money, though, many analysts say a culture in which restraints are used too soon, too frequently and for the wrong reasons must be changed.
"The single biggest prevention method is the avoidance of restraints to begin with,'' Sundram said. "It is often the training and opinions of staff that dictate restraints, rather than patient behavior.''
In Tennessee, "the changes were top-down, bottom-up and a hard sell everywhere,'' Sullivan said. Before taking the top Tennessee job, Sullivan spent 27 years as an official in Connecticut's Department of Mental Retardation.
Reducing restraint use was just one of many changes forced on Tennessee by two lawsuits filed by the U.S. Department of Justice and by patient advocates. "It was a system that was disintegrating,'' said Ruthie Beckwith of People First of Tennessee, a patient advocacy organization that sued the state.
The state responded with new leadership, more money and staff and an intensive training regimen emphasizing calming words instead of brute force.
The total cost for the Jordan Center: $12,665 for training in restraint use and alternative methods; $255,372 annually in additional staffing to address not only restraint issues but massive deficiencies in overall patient care.
The changes in technique weren't easy on staff. About a half-dozen aides quit. Others groused. But most stayed and changed.
"It was a rough couple of months,'' said Robert Zavala, an aide at Jordan. "At first, they just told us we couldn't put our hands on them. Everyone was like, 'Oh, so all I can do now is run away?' ''
Bernard Simons, the Clover Bottom superintendent who oversaw the transition, remembers a defining moment. He received a frantic call from staffers at Jordan saying a patient was smashing furniture and asking whether they could restrain him.
"I said, 'Let him break it,' '' Simons said. "So you're going to risk hurting yourself or the patient for a $100 coffee table? The state will buy a new one.''
The changes are both profound and surprising to staff and patients who remember the old ways.
"Before, we weren't earning their respect, it was just fear,'' said Overton, the burly aide who still wears a belt that says "Boss.''
"Now, I'm more of a counselor or big brother than an enforcer,'' Overton said. Like a Cold War relic, he now uses skills other than just his brawn, such as his woodworking knowledge, which he passes on to patients in a new class he teaches.
"I used to get shuffled a whole lot of times when I would go off and hit someone,'' said David Holland, 24, who has been at the Jordan Center for 2 1/2 years. "Now, they give us a lot more time to chill out, calm down. It's getting better each day.''
WAYS TO IMPROVE THE SYSTEM
Based on interviews with health care experts, workers, advocates, patients, hospital administrators and government officials, The Courant's investigation has highlighted ways to make restraint use less dangerous. They include:
Better and more frequent training.
Staff should be trained regularly in nonphysical methods to calm patients, and in safe techniques to restrain patients.
Universal CPR training.
All hands-on staff should be trained in the use of CPR, which not only enables workers to save lives but to recognize the patient's signs of distress.
Uniform national standards.
National standards should be set on how and when to use restraints. Minimum staff training should be required in their use.
Monitoring patients in restraint.
Patients in physical restraints should be monitored by a staffer not involved in the restraint. Patients in mechanical restraints should be monitored constantly or at frequent, regular intervals.
Elimination of bad techniques.
Restraints that are found to be dangerous, such as face-down floor holds and mouth coverings, should be banned nationwide.
Universal reporting of restraint deaths.
Restraint-related deaths and injuries should be reported to a national clearinghouse so lessons can be shared and potentially deadly errors averted.
Professional research needs to be done in this largely unexplored area. In particular, the issue of children being restrained warrants concerted study.
All sudden, unexpected deaths such as those following a restraint should be thoroughly investigated by medical examiners and police.
[Here ends the BODY of Day Five's article.
Photo captions and Graphics descriptions follow.]
Caption: PHOTO 1: MIKE PIGNONE, an aide at the Harold W. Jordan Center, talks with a patient on the grounds of the Nashville facility. Recent changes at the center are the result of Tennessee's efforts to minimize the need to physically restrain patients. "If we could do it here, it can be done anywhere,'' said a Jordan Center administrator.
PHOTO 2: HE STILL WEARS A BELT THAT SAYS "BOSS,'' but these days Will Overton sees himself more as a big brother to patients at the Jordan Center. The center is an example of how mental health facilities can, through sufficient staffing and intensive training of aides, reduce the inclination to physically restrain patients.
[Here ENDS Day Five: From 'Enforcer' To Counselor.]
October 15, 1998
Illustration: PHOTO 1: (b&w), Rick Hartford / The Hartford Courant
PHOTO 2: (color)
Source: ERIC M. WEISS; Courant Staff Writer
[NO Photos or Graphics are available for posting.
However, their Captions remain included.]
FIGHTING IN THE NAME OF THEIR SON
Gagging the mouths of patients was standard procedure during restraints at the Charter Greensboro psychiatric hospital.
This "homegrown'' practice, which was included in no training manual, led to the death last March of 16-year-old Tristan Sovern. He suffocated after being restrained face-down by seven staffers who wrapped a towel and a bed sheet around his head to prevent him from biting or spitting. "I cannot understand how, when they heard my son screaming that he couldn't breathe and that they were choking him, not one of those people said, 'Stop,' '' said Jean Allen, Sovern's adoptive mother.
Jean Allen and her husband, Richard, who have six other children, including four adopted ones with special needs, are fighting for Sovern now just as strongly as they did when he was alive.
They plan to draft and lobby for national standards that would become known as "Tristan's Law.'' The legislation would require mental health aides to be licensed and would ensure minimum qualifications and training. It would also require criminal background checks of all prospective mental health aides.
"I don't think as a nation that we should allow people who don't have proper training, who are not supervised properly, to go and work with those who need the very best,'' Allen said. A college professor with a doctorate in child development, Allen once worked in psychiatric hospitals in California.
Although individual states and institutions set individual training levels, there are no national standards on the proper use of restraint. Only three states -- California, Colorado and Kansas -- have active licensing laws in place for mental health aides.
Sovern, who had developmental and emotional problems, had been placed on a suicide watch at Charter Greensboro, part of the nation's largest chain of psychiatric facilities.
Acting on a tip from another patient that Sovern might be trying to hurt himself with a fish hook, seven staffers burst into his room to restrain him.
The aide leading the chargehad twice been convicted of assault outside of work, including an incident in which he tried to run down someone with a car.
He was hired after the first conviction, then kept on staff after the second.
Joel Weiden, a spokesman for the hospital's owner, Charter Behavioral System, said he did not know why the worker was kept on staff. But the Greensboro facility no longer uses mouth coverings, he said, "and I'd be surprised if any other Charter facilities still use them.''
Weiden blamed mistakes in restraint use on the lack of national standards -- the same sort of standards Jean Allen is now fighting to ensure.
"There is no national standard, and no direction from government agencies or any of the trade organizations,'' said Weiden, whose chain of hospitals had another restraint-related death just three months before.
"So each facility,'' he said, "has been left to develop its own policies.''
To Allen, that is simply unacceptable.
"People would be up in arms if they found out animals were being treated this way at the local animal shelter,'' she said. "We owe no less for our children.''
ONE SET OF LICENSING RULES
Colorado, Kansas and California are the only states that license mental health aides, or psychiatric technicians. Here are the main parts of Colorado's licensing law. Psychiatric technicians are licensed to care for mentally ill and developmentally disabled patients under the direction of a doctor and the supervision of a registered nurse. They are licensed to administer selected treatments and medications as prescribed by a doctor.
TO OBTAIN A LICENSE, A CANDIDATE MUST:
* Earn a high school diploma or equivalent.
* Earn a diploma from a state-accredited psychiatric technician educational program.
* Pass a state licensing program.
* Have a background that does not include a felony conviction, among other things.
THE STATE BOARD OF NURSING ACCREDITS EDUCATIONAL PROGRAMS FOR PSYCHIATRIC TECHNICIANS. TO BECOME ACCREDITED, A SCHOOL MUST HAVE A CURRICULUM THAT INCLUDED:
* Basic training in clinical practices and nursing principles.
* Special training if the candidate is to work with people with developmental disabilities.
* Special training if the candidate is to work with children.
THE BOARD OF NURSING MAY REVOKE A LICENSE OR TAKE OTHER DISCIPLINARY ACTION IF, AMONG OTHER THINGS, A PSYCHIATRIC TECHNICIAN:
* Is convicted of a felony.
* Acted negligently in the care of a patient, or acted against the health and safety of the patient.
* Falsified patient records or failed to make essential entries in patient records.
Employers must report to the board of nursing any disciplinary action against psychiatric technicians, or any resignations in lieu of disciplinary action.
The law does not prevent family or friends of a patient from providing any care that falls outside the specified duties of the technician.
SOURCE: Colorado Board of Nursing
Caption: PHOTO 1: CLUTCHING A PICTURE OF HER SON, Jean Allen is comforted by her husband, Richard Allen, at Tristan Sovern's grave in Liberty, N.C. Sovern, 16, died last March at the Charter Greensboro psychiatric hospital after being restrained. The Allens now are working to draft national standards requiring that mental health aides be licensed, meet certain minimum qualifications and be subject to criminal background checks. The legislation would be known as "Tristan's Law.''
PHOTO 2: HIS MOTHER KEEPS AN ALBUM with photos and this award that Sovern won in school when he was 12.
October 15, 1998
Illustration: PHOTO: (color) mug
Source: DWIGHT F. BLINT; Courant Staff Writer
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However, their Captions remain included.]
It is too late to help 11-year-old Andrew McClain.
But thanks to the bitter lessons of his death, one life has been saved and another has been improved. Andrew, a state foster child, died in restraint in March at Elmcrest psychiatric hospital. Two months later, staffers who had just undergone state-ordered CPR training saved an adult patient whose heart was failing.
And because of improved record-keeping and monitoring required in a state consent order, workers noticed a child was at risk of dehydration and were prepared to treat the condition.
The incidents are described in reports filed by a state monitor. The monitor was assigned to oversee improvements at Elmcrest, a subsidiary of Hartford-based St. Francis Care, after state investigators found numerous license violations.
The monitor's records reflect major staffing and policy changes at Elmcrest in the six months since Andrew's death.
"None of this is going to bring him back,'' points out Andrew's mother, Lucinda McClain of Bridgeport. Nonetheless, McClain said, she is glad to hear changes might save other lives.
Unlike many similar cases, Andrew's death was extensively investigated by police and child welfare officials, whose findings were widely distributed.
The question now is whether Andrew's legacy will have a lasting impact. Will it improve the level of care not only at Elmcrest, but at every Connecticut facility that treats children?
Few comprehensive, statewide reforms have been put in place yet and even at Elmcrest, where state scrutiny remains intensive, questionable practices have persisted.
Linda Pearce Prestley, the state's child advocate, who harshly criticized Andrew's care in two reports this year, expects the improvements undertaken at Elmcrest to spread across Connecticut.
Records show Elmcrest has cut back on its use of restraint holds, workers now use a nationally recognized restraint technique, and regular, specialized restraint training has been put in place.
The hospital has increased the number of workers in each unit, while reducing the number of patients. It also has established a policy to call 911 immediately in an emergency, among other measures requested by Pearce Prestley and the state Child Fatality Review Board.
Yet no other facility in the state has been asked to ensure the same level of care, and at least two other comprehensive reforms have yet to come to fruition.
Department of Children and Families Commissioner Kristine D. Ragagliarecommended last spring that the state standardize restraint practices. A proposal has been drafted, but is still being reviewed by a variety of state agencies.
DCF has prohibited facilities from using face-down restraint holds -- the type that killed Andrew -- on all children who are in state custody. But a plan to broaden the ban to encompass all children in all state-licensed child-care facilities has yet to be put in place.
Despite the lack of progress on those fronts, DCF has intensified its oversight of psychiatric hospitals and other service providers.
Dr. Gary Blau, director of DCF's bureau of quality management, said the agency reviewed 25 programs in the first six months of this year compared to five over the same period last year.
DCF learned the hard way from the Andrew McClain case not to trust the existing system of oversight.
"To hear that a facility is licensed by the Department of Public Health, the federal government and [the Joint Commission on the Accreditation of Healthcare Organizations], I thought there was no reason for me to worry about the quality of programming,'' Ragaglia said.
"But I guess I was proven wrong.''
After investigating Natchaug Hospital in Mansfield and Hall-Brooke Foundation in Westport last summer, for instance, DCF asked the facilities to stop accepting state foster children. Both programs were reinstated after making improvements.
"We're certainly showing much greater visibility in the psychiatric community than we ever had before,'' Blau said.
But DCF may be alone on that front.
Cynthia Denne, director of the division of health systems regulations for the Department of Public Health, said the circumstances surrounding Andrew's death have resulted in no policy changes at her agency.
The department now inspects psychiatric hospitals once every four years, and plans to maintain the status quo.
Currently, the health department is overseeing the state monitor stationed at Elmcrest. But state regulators will pull the monitor this fall if they determine the hospital is on the road to compliance.
At that point, Elmcrest will be forced to stay on track by its own "commitment to quality care,'' Denne said. She conceded that Elmcrest's changes, while significant, are not necessarily permanent.
And over time, strategies and philosophies can change.
After Andrew's death, Elmcrest and St. Francis Care kicked their public relations and legal teams into high gear. Company officials held press conferences and placed full-page newspaper advertisments promising to set "benchmarks for excellence.''
But in recent weeks hospital officials declined requests for interviews and for a tour of Elmcrest, and they did not respond to a series of written questions submitted by The Courant. St. Francis issued a six-paragraph statement pointing out some of the changes it has made, and the appointment of Ronald LaPensee as Elmcrest's chief administrative officer.
St. Francis cited potential litigation for its reluctance to comment. The potential became real this week when the estate of Andrew McClain served hospital officials with a lawsuit charging negligence and recklessness.
As this watershed case enters the court system, the care of thousands of other children will remain an issue. And for all the efforts made after Andrew's death, state records show the job of ensuring quality care is a continuing one.
On June 21, the monitor's records show, an Elmcrest staff member covered an 8-year-old boy's mouth with a glove during a restraint -- a practice condemned by experts. In the same incident, staffers delayed calling for help.
Afterward, the state monitor who had witnessed the event met with hospital administrators to devise new policies.
Bettering the care of troubled children has historically been a slow process, said Martha Stone, an attorney who helped lead a landmark 1989 lawsuit against the state on behalf of neglected children.
But Stone, director of the Center for Children's Advocacy at the University of Connecticut School of Law, is optimistic that Andrew did not die in vain. People are growing more aware, momentum is growing.
"I think,'' she said, "there is going to be some kind of legacy.''
Caption: PHOTO: Andrew
Hartford Courant October 17th-published Related Article:
REFORM URGED IN USE OF RESTRAINTS
U.S. LAWMAKERS RESPOND TO REPORT ON DEATHS
Hartford Courant October 24th-published Related Article:
GROUPS CALL FOR REFORM IN USE OF RESTRAINTS
MENTAL HEALTH PROVIDERS REACT TO REPORTS OF 142 DEATHS IN FACILITIES
Hartford Courant DECEMBER 16th-published Related Article:
USE OF IMPROPER RESTRAINTS WIDESPREAD, GROUPS SAY
How the Courant Conducted Its Investigation
"Glossary of Terms" used by the authors
Hartford Courant DEADLY RESTRAINT Investigation DATA BASE
DAY ONE; October 11: A Nationwide Pattern of Death
DAY TWO; October 12: Little Training, Few Standards, Poor Staffing Put Lives At Risk
DAY THREE; October 13: Patients Suffer In A System Without Oversight
DAY FOUR; October 14: People Die And Nothing Is Done