AN INVESTIGATION INTO THE EXCESSIVE USE
OF RESTRAINT AT THE EMERGENCY DEPARTMENT
OF FLETCHER ALLEN HEALTH CARE

Charlie Abbate,
Staff Attorney

Ed Paquin,
Executive Director

Vermont Protection & Advocacy, Inc.
141 Main St. Suite 7
Montpelier, VT 05602
(802)229-1355
www.vtpa.org

VP&A is the Protection & Advocacy System for the state of Vermont
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I. INTRODUCTION
This report documents Vermont Protection & Advocacy Inc.’s (VP&A’s) investigation
into the Fletcher Allen Health Care (FAHC) Emergency Department’s (E.D.’s) treatment
of RD on August 6, 2006. At the time of admission, 11:37 a.m., RD was demonstrating
“agitated” and “paranoid behavior”. As a result, he was placed in the mental health
section1 of the E.D. Security Officers (SOs) were posted in the hallway outside of RD’s
room. RD remained in the E.D., awaiting treatment, for nine hours. During this period
he was physically restrained2 on six occasions. At 9:37 p.m. RD was discharged from the
E.D. and escorted in handcuffs to FAHC’s inpatient psychiatric unit.
The numerous incidents of physical restraint significantly impacted RD’s mental health
and ultimately had an adverse effect on his recovery. According to RD’s Resident
Psychiatrist, RD perseverated over the occurrences of August 6, 2006 for over a month.
FAHC Progress Notes detail the traumatic impact of RD’s experience in the E.D. in the
days immediately following the incidents:
(Progress Notes 8/07/06) Patient is angry and irritable very upset about situation in the
ED last night and about being in the hospital.
(Progress Notes 8/09/06) Patient is very upset still about the “abuse” he received in the
ED.
(Progress Notes 8/10/06) He continues to be angry about incidence (sic) at admission...
This report will provide the findings of VP&A’s independent investigation into the
August 6, 2006 incidents. We would like to thank FAHC for their cooperation and
seemingly genuine interest in the outcome of our investigation.
At the conclusion of our investigation VP&A found that FAHC diverged from several
standards regarding the proper care of patients with acute mental illness. These
divergences caused RD to suffer from unnecessary distress, physical injury, and

1

In VP&A’s interview with E.D. Nurse, she described the E.D. as being broken down into sections. The
E.D. Nurse referred to the section in which RD was placed as the mental health section.
2
The term “restraint” includes either a physical restraint or a drug that is being used as a restraint. A
physical restraint is any manual method or physical or mechanical device, material, or equipment attached
or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or
normal access to one's body. 42 CFR 482.13(f).

2

Iatrogenic Trauma3. In this report, VP&A provides recommendations aimed at
remedying the concerns identified and improving FAHC’s E.D. care and treatment for
patients with acute mental illness.
II. BACKGROUND
RD is twenty four years old. He was raised in Baltimore, Maryland. He has two siblings
ages seventeen and twenty two. His parents and seventeen year old sister continue to
reside in Baltimore. RD relocated to Burlington, Vermont in 2001 after being accepted to
the University of Vermont (UVM). While attending UVM RD studied Forestry and
maintained a GPA of over 3.01. He is currently not attending UVM, however he intends
to return in the near future in order to complete a degree in Forestry. Ultimately RD
would like to work as a professor in the environmental field.
A. Inpatient Hospitalizations
RD has a documented history of mental illness. His first episode occurred in August of
2002 while attending his second year at UVM. Subsequent to this episode, RD has been
hospitalized as an inpatient on four occasions. Two of these hospitalizations were at
FAHC. Records from these inpatient hospitalizations describe RD as experiencing
“auditory hallucinations” and reacting to “internal stimuli.” RD was ultimately given a
diagnosis of Bipolar Affective Disorder.
B. July 23rd and August 4th 2006 FAHC Emergency Department Visits
In addition to RD’s four inpatient hospitalizations, on two occasions he has visited the
FAHC E.D. in regard to his psychiatric condition. The first of these visits occurred on
July 23, 2006 at 1:59 p.m. FAHC E.D. records of this visit are scant and offer limited
insight into RD’s mental health status. They do note however that RD was exhibiting
“bizarre behavior.” RD left the E.D. after waiting for an hour and a half to be seen by a
Howard Center for Human Services (HCHS) Crisis Evaluator.
RD’s second E.D. visit occurred on August 4, 2006 at 1:27 a.m. According to the FAHC
E.D.’s Physician Summary, RD was brought into the E.D. by friends. Again
documentation of this visit is scant. However, it is noted in the Physician’s Summary
that RD was exhibiting “bizarre” and “paranoid behavior.” RD left the E.D. at
approximately 2:45 a.m.

3

Trauma survivors may be especially vulnerable to additional traumatic and/or iatrogenic (physician-caused)
experiences that occur within the psychiatric setting. For example, routine use of seclusion, restraints, or
handcuffs may serve to recapitulate previous traumatic experiences, and thereby exacerbate symptoms of PTSD.
Cohen, L. J. (1994). Psychiatric hospitalization as an experience of trauma. Archives of Psychiatric Nursing, 8,
78-81; Frueh, B. C., Dalton, M. E., Johnson, M. R., Hiers, T. G., Gold, P. B., Magruder K. M., Santos, A. B.
(November 2000). Trauma within the psychiatric setting: conceptual framework, research directions, and policy
implications. Administration and Policy in Mental Health, Vol.28, No. 2.

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On the same evening, at 4:45 a.m., the E.D. staff found RD lying outside of the hospital.
RD was again admitted to the E.D. Shortly thereafter he was evaluated by HCHS Crisis
Evaluator #1. According to Crisis Evaluator #1’s notes, “Clt’s mood and behavior
fluctuated rapidly between being anxious and depressed due to apparent grief over his
condition verses being fearful based on paranoid delusional thought content.” RD did not
meet the criteria for involuntary admission and as a result, RD was discharged to
ASSIST4 by Physicians Assistant (PA) #1. RD had an ongoing relationship with HCHS,
which operates the ASSIST Program.
C. Howard Center for Human Services
RD initially requested Community Rehabilitation and Treatment (CRT) services through
HCHS on July 28, 2005. His request for services followed a 2005 hospitalization at
Central Vermont Hospital (CVH). RD was evaluated by a HCHS’s Dr. The Dr. noted
that RD “voices paranoid delusions that he believes there may be CIA agents watching
him and grandiose delusions that he can hear the inner voices of others.” (HCHS
Diagnosis and Evaluation, 7/28/2005).
On February 28, 2006 RD was discharged as a client of HCHS due to his relocation to
Baltimore. On July 13, 2006 RD returned to Vermont and reapplied for CRT services.
RD was evaluated by a second HCHS’s Dr. The Dr. recommended that RD be accepted
for CRT services noting that during previous episodes he had “experienced decreased
sleep, racing thoughts, disorganized behavior, and prominent grandiose and paranoid
delusions.” (HCHS Diagnosis and Evaluation, 7/13/2006).
Upon re-acceptance for CRT services, RD attended an appointment with a HCHS Dr. on
July 27, 2006. In his assessment the Dr. stated that RD “feels that he is being potentially
followed and/or watched…” (HCHS Physicians Progress Note, 7/27/06). RD was
scheduled for a follow up appointment on August 3, 2006. RD failed to appear for this
appointment.
On the following day, August 4, 2006, after being discharged from the FAHC E.D., RD
was admitted to the HCHS ASSIST Program. HCHS records document that on August 4,
2006 RD was “manic, psychotic, delusional” and had “ripped an I.D. badge from a
doctor’s coat during a FAHC interview…” (HCHS Discharge Summary/ Transition
Plan, 8/05/2006).
RD spent the day and evening of August 4th and the day of August 5th at ASSIST.
According to HCHS records, “his stay was marked by increasing paranoia….” (HCHS
Discharge Summary/Transition Plan, 8/05/2006). He was noted as asking the staff if
4

The ASSIST Program is a short-term psychiatric crisis residential program that offers hospital diversion,
stabilization, and step-down services to people experiencing an acute emotional crisis. The program
primarily serves persons with psychiatric disabilities and is designed as an alternative to inpatient
hospitalization. The program is provided by the Howard Center for Human Services. See
http://www.howardcenter.org/ABHS/abhs%20 programs/abhscrisissercc.htm

4

they knew of a good place to hide because the CIA was after him. (HCHS Discharge
Summary/Transition Plan, 8/05/2006).
III. AUGUST 6, 2006 FAHC EMERGENCY DEPARTMENT ADMISSION
A. Events Leading Up to E.D. Admission
As evidenced by HCHS and FAHC E.D. records, in the weeks leading up to August 6,
2006 RD’s mental health began to deteriorate. On the morning of August 5, 2006 RD left
HCHS’s ASSIST to have breakfast with his parents. During this period RD was acting
extremely agitated. Due to RD’s agitation his parents contacted the Burlington Police
Department (BPD) in order to have RD escorted back to ASSIST.
RD remained at ASSIST for the duration of the morning, however he left that afternoon.
RD may have spent the evening of August 5, 2006 at a friend’s apartment. On the
morning of August 6, 2006, RD called his father and requested that they meet. RD
insisted that his father bring neither his mother nor the police. Fearing that RD was
suicidal, RD’s parents notified the BPD in order to have RD transported to the E.D.
Upon arrival officers from the BPD were able to convince RD to accompany them to the
FAHC E.D.
B. Documented Interactions with Mental Health Care Professionals in the E.D.
RD arrived at the FAHC E.D. sometime after 11:00 a.m. His official registration time is
noted as 11:37 a.m. The hospital staff was unable to triage5 RD in the customary fashion
due to his mental state. As a result the E.D. Nurse triaged RD in an examination room.
The examination room was located in the Mental Health section of the E.D. According
to the E.D. Nurse several exceptions to the normal routine were made for RD due to his
level of agitation and other symptoms. These exceptions included not requiring RD to
change into hospital-approved clothing and not requiring RD to be searched by SOs.
Aside from triaging RD, the E.D. Nurse had numerous other contacts with him
throughout the day. The E.D. Nurse considered herself to be the nurse responsible for
RD’s care throughout his stay in the E.D.
At 12:24 p.m. RD was evaluated by P.A. #2. P.A. #2 was the senior medical provider in
charge of RD’s care. According to the security video this evaluation lasted
approximately three minutes. Despite requests, no documentation of this meeting has
been provided to VP&A. During VP&A’s interview with P.A. #2 he indicated that his
first visit with a patient is ordinarily an initial evaluation. Other than the fact that RD was
delusional, P.A. #2 did not remember specifics of this initial evaluation. However, P.A.
#2 did remember that after the evaluation he contacted a Crisis Evaluator due to the fact

5

Triage is an initial assessment of patients whereby they are sorted on the basis of need to ensure that
medical staff are most effectively utilized. At FAHC patients are normally triaged in the triage room which
is located in the front of the E.D. near the waiting room.

5

that RD was exhibiting “paranoid behavior.” P.A. #2 had various other contacts with RD
throughout the day.
At 1:08 p.m. Crisis Evaluator #2 from HCHS met with RD. According to the security
surveillance, their meeting lasted for approximately twenty-two minutes. According to
Crisis Evaluator #2’s report, RD appeared to be “suspicious”, “frightened” and
“paranoid.” Crisis Evaluator #2 went on to note that RD stated, “the CIA is around and
after me.” Crisis Evaluator #2 stated in his interview with VP&A that he had several
other contacts with RD throughout the day.
At 2:18 p.m. FAHC surveillance video shows the Psychiatric Resident having contact
with RD. This contact lasted for under two minutes. According to our interview with the
Psychiatric Resident the short interaction was due to RD’s unwillingness to cooperate.
VP&A has not been provided any records documenting this interaction.
At 5:35 p.m. FAHC surveillance video shows a second interaction between the
Psychiatric Resident and RD. This interaction lasts until 6:02 p.m. In an interview with
VP&A, the Psychiatric Resident stated that during this time period RD was “extremely
paranoid delusional … afraid of anyone who entered the room.” As a result of his mental
state, the Psychiatric Resident made the decision to admit RD involuntarily to the FAHC
psychiatric unit. The Psychiatric Resident went on to state that over the next several
hours he briefly checked in on RD while attempting to find a psychiatric bed for him.
There is no documentation of any of these contacts other than a physician’s summary
with a time of examination of 2:45 p.m. According to the surveillance video there is no
contact with RD at that time.
C. Restraints
Throughout RD’s August 6, 2006, nine hour stay in the FAHC E.D. he was physically
restrained by SOs six times. The remainder of this section will detail each restraint. The
details have been derived from hospital records, video surveillance, and interviews.
1st Restraint
At approximately 2:55 p.m. RD was standing in the hallway outside of his examination
room, room 37. While in the hallway, he was talking to the SOs. According to responses
in interviews conducted by VP&A, the SOs stated that RD was “verbally abusive”,
“cursing”, and stating he could leave the hospital if he wanted. The SOs went on to state
that RD behavior was bothering other patients in the E.D. In response to RD’s
verbalizations the SOs used verbal encouragement to move him back in front of the door
to his room. Once in the doorway SOs #1 and #2 took RD by his arms and physically
escorted him onto the bed. The SOs then left the room and shut the door. RD denies that
he used any vulgar or abusive language.
During VP&A’s interviews, all of the SOs, except SO #1, stated that RD made no
threatening or suicidal statements. SO #1 felt that RD’s statement that he could leave the

6

hospital constituted threatening language. The SO in charge, Lieutenant (Lt.), attributed
the restraint not to threatening behavior, but rather to nursing staff’s direction to keep RD
in his room. SO #2 stated his opinion that nursing staff’s request to keep patients in their
room is enough in itself to use force to carry out that order.
2nd Restraint
At approximately 3:06 p.m., RD was once again standing in the doorway of room 37.
Again while in the doorway he was speaking to the SOs stationed outside. According to
interviews, RD was again loud and abusive and in general disruptive. In response to
RD’s behavior, and after checking with the nursing staff, the Lt. pushed RD into his room
while SO #2 secured the door. In VP&A’s interviews, all SOs, except SO #1, believed
that RD did not pose a threat of harm. SO #1 felt that RD’s threat to leave the hospital
did pose a threat of harm to the SOs. Again, RD denies that he used abusive language.
3rd Restraint
At approximately 3:17 p.m. RD was again restrained by the SOs. Prior to this incident
RD was in the restroom across the hall from his examination room and adjacent to the
nursing station. While in the restroom RD pushed the call bell. Nurse #2 responded to
the bell by entering the bathroom. She informed RD that she was not his nurse.
Following a brief discourse, Nurse #2 left the bathroom and began to walk away. RD
followed Nurse #2 out of the bathroom and down the hall. As RD approached the SOs,
they grabbed RD and took him down to the floor.
The SOs involved in the incident believed that RD posed a threat to Nurse #2. They
stated that it appeared Nurse #2 did not want RD to pursue her and was moving away
quickly. The SOs stated that at first they attempted to place themselves between the
Nurse #2 and RD. When their presence did not prevent RD from proceeding they
attempted to use a MOAB6 complaint restraint. However, due to a blanket wrapped
around RD, which made it difficult to control RD’s arms, that restraint was not possible.
The SOs improvised in order to take RD to the ground.
After the SOs gained control on the ground, RD was placed in an escort hold and led
back into room 37. According to SO #1, RD attempted to grab a pen from his own
pocket. As a result, the SOs forcefully placed RD on the bed in order to recover the pen.
RD was driven head first into the bed. After a brief struggle the SOs removed the pen
from RD’s hand. According to RD, he had brought in the pen upon admission. There
was nothing in the record to demonstrate that any measures were taken to ensure that RD
was not given another pen.
4th Restraint

6

MOAB is an in-depth training program that teaches individuals how to recognize, reduce, and manage
violent and aggressive behavior. MOAB Instructor Manual, Roland W. Ouellette, 1993.

7

At approximately 4:19 p.m. RD was again restrained by the SOs. Prior to this incident,
RD’s mother entered room 37. SO #1 stated that he noticed that RD’s mother was
carrying a bag that appeared to contain prescription medication bottles. RD’s mother
denies having carried in any medications and suggests that RD was in possession of these
medications from the time of admission. As a result of SO #1’s perception, Mr. #1
informed Lt. Lt that prescription medications may have been brought into RD’s room.
Lt. Lt relayed this information to the E.D. Nurse. The E.D. Nurse requested that the Lt.
confiscate the medications.
In an effort to confiscate the medications, the SOs approached RD’s room. SO #3
entered the room first while the other three SOs waited just outside of the doorway. SO
#3 stated that he explained to RD that he needed to take the medications. RD refused to
relinquish the medications. SO #2 stated in his interview with VP&A that at one point
during SO #3’s conversation, RD agreed to relinquish possession of his medications to
his mother. However according to SO #1, RD stated that, “he would give them to his
mom only, but they would stay in the room.” RD’s mother acknowledged that she would
give the SOs the medications and RD refused to pursue this course.
For under a minute SO #3 continued to ask RD for the medications while the other SOs
waited behind SO #3 in the hallway. RD continued to refuse to comply with SO #3’s
request. SO #3 moved toward RD and reached for the medications. RD got off the bed,
where he had been sitting, and moved toward the corner of the room. RD held the
medications over his head. SO #2 and SO #3 followed RD as he moved to the corner.
The SOs attempted to gain control over the medications by grabbing for them and RD’s
arms. While SO #3 was pulling on his arm, RD threw the bag of medications toward his
mother. In the process the bag of medications knocked off SO #1’s eyeglasses.
Eventually the SOs gained control of RD and forced him down on the bed. According to
SO #1, “due to my vision I was unable to see well, so I held his head down on the bed till
someone could relieve me to retrieve my glasses.” According to Mrs. Dyer, SO #1 was
holding RD by the neck. Due to the angle of the surveillance tape SO #1’s hand
positioning was unclear.
While being restrained on the bed by the SOs, RD was searched. The search lasted for
approximately three minutes. As a result of the search additional medications, paper, a
lighter and matches were recovered.
During interviews conducted by VP&A the SOs gave varying answers as to the threat
that RD posed while he remained in possession of the medications.
The Lt. stated that RD had not threatened to eat the medications, was not
talking about suicide and was not wielding the bag in a threatening
manner. However, the Lt. felt that RD’s positioning in the corner of the
room was threatening.

8

SO #3 stated that he did not remember RD making any threats with the
bag of medications. Furthermore, SO #3 did not feel that RD’s move to
the corner was a threat to staff; however he felt that the act of throwing the
medications was threatening.
SO #1 was clear in stating that RD did not make any verbal threats to use
the medications in any way. Furthermore, SO #1 did not feel that RD’s
move to the corner was threatening.
SO #2 had no opinion as to whether the bag of medications posed a threat.
5th Restraint
The fifth restraint occurred at approximately 6:35 p.m. At this point the SOs were no
longer present. An Emergency Medical Technician (EMT) was posted as a sitter7 for
RD. With the EMT’s permission RD was sitting on a chair in the hallway outside of his
room. The EMT was sitting next to RD. RD can be seen via security surveillance
abruptly standing up and heading out of the hallway. Prior to reaching the exit RD was
met by SOs #3 and #2. The SOs led RD back to his room under a resistive escort. The
details of this encounter were not captured on video surveillance.
6th Restraint
The sixth restraint occurred at approximately 8:37 p.m. Prior to the restraint RD was
sitting at the nursing station at the end of the hallway. At some point a clerk from the
registration department approached and presented RD with admission forms and a pen to
use in filling them out. According to the EMT, upon presentation of the paperwork, RD
became agitated and began speaking and cursing in a loud voice.
The EMT approached RD in an attempt to diffuse the situation. Soon thereafter RD’s
parents arrived in the hallway. The EMT noted that the presence of his parents further
agitated RD. At 8:35 p.m. the SOs approached RD. With the presence of the SOs there
were now six individuals surrounding RD (three SOs, RD’s parents, and the EMT). The
SOs requested that RD lower his voice. According to reports and interviews with the
SOs, RD continued to yell and swear in a loud manner. RD alleges that he was confused
by the paperwork and that prior to the confrontation with the SOs he was neither yelling
nor cursing. RD goes on to state that one of the SOs stated, “you’re going to be in the
hospital for a long time.”
After brief attempts at calming RD, the Lt. informed RD that his room on Shepardson Six
was now available. RD continued to yell and refused to accompany the SOs to
Shepardson Six. According to the Lt. at this point the SOs identified that RD was
holding a pen. Lt. requested that RD hand over the pen. Lt. then noted that RD began
holding the pen in a “threatening manner”. Lt. Lt did not note what was threatening
7

According to VP&A’s interview with the EMT, all EMT’s are trained in MOAB for the purpose of sitting
with potentially dangerous patients to ensure that the patients do not pose a threat of harm to self or others.

9

about the manner in which RD was holding the pen. Review of the video does not clarify
how the pen was being held.
As a result of the SOs’ perception, SOs #1 and #2 initiated a resistive escort while Lt.
attempted to remove the pen. RD continued to struggle while being restrained by the two
SOs and the Lt. The Lt. ordered handcuffs be applied to RD. As handcuffs were being
applied RD broke free. In an attempt to subdue RD the three SOs took him to the ground.
According to the Lt.’s statement, “[I]n my attempt to stop the subject from fleeing by
grabbing him around the shoulder to slow him down my arm went around his neck and
we went to the ground.” Upon hitting the ground RD nearly hit his head on a laundry
basket in the hallway. After a brief struggle on the ground RD was handcuffed, placed in
a wheel chair and escorted to Shepardson Six.
IV. LAW, STANDARDS & POLICY
FAHC’s treatment of patients is governed by several standards of care. These standards
include Center for Medicare and Medicaid Services (CMS) Conditions of Participation
(COP), the Joint Commission on Accreditation of Health Care Organizations (JCAHO),
FAHC’s internal policies, and Management of Aggressive Behavior (MOAB) techniques.
The remainder of this section will cite the standards that are relevant to VP&A’s
investigation.
CMS Condition of Participation8: Patient’s Rights, 42 CFR 482.13(f)
(1) The patient has the right to be free from seclusion and restraints, of any form,
imposed as a means of coercion, discipline, convenience, or retaliation by staff. The term
“restraint” includes either a physical restraint or a drug that is being used as a restraint. A
physical restraint is any manual method or physical or mechanical device, material, or
equipment attached or adjacent to the patient's body that he or she cannot easily remove
that restricts freedom of movement or normal access to one's body. A drug used as a
restraint is a medication used to control behavior or to restrict the patient's freedom of
movement and is not a standard treatment for the patient's medical or psychiatric
condition. Seclusion is the involuntary confinement of a person in a room or an area
where the person is physically prevented from leaving.
(2) Seclusion or a restraint can only be used in emergency situations if needed to ensure
the patient's physical safety and less restrictive interventions have been determined to be
8

CMS develops Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) that health care
organizations must meet in order to begin and continue participating in the Medicare and Medicaid
programs. These minimum health and safety standards are the foundation for improving quality and
protecting the health and safety of beneficiaries. CMS also ensures that the standards of accrediting
organizations recognized by CMS (through a process called "deeming") meet or exceed the Medicare
standards set forth in the CoPs / CfCs. http://www.cms.hhs.gov/CFCsAndCoPs/

10

ineffective.
(3) The use of a restraint or seclusion must be—
(i) Selected only when less restrictive measures have been found to be ineffective
to protect the patient or others from harm;
(ii) Implemented in the least restrictive manner possible;
(iii) Ended at the earliest possible time.
(B) The treating physician must be consulted as soon as possible, if the
restraint or seclusion is not ordered by the patient's treating physician.
(6) All staff who have direct patient contact must have ongoing education and training in
the proper and safe use of seclusion and restraint application and techniques and
alternative methods for handling behavior, symptoms, and situations that traditionally
have been treated through the use of restraints or seclusion.
CMS Interpretive Guidelines §482.13(f)
Handcuffs; manacles; shackles; and other chain type devices are considered law
enforcement restraint devices and would not be considered safe appropriate health care
restraint interventions for use by hospital staff to restrain patients in hospitals.
JHACO9
Standard PC. 12.50
1. Nonphysical techniques are always the preferred intervention
Standard PC.1260: Restraint or seclusion is limited to emergencies in which there is an
imminent risk of a patient physically harming himself or herself, staff or other, and
nonphysical interventions would not be effective.
Elements of Performance:
1. Restraint or seclusion is used only when nonphysical interventions are
ineffective or not viable and when there is an imminent risk of a patient
physically harming him or herself, staff or others
2. The type of physical intervention selected considers information
learned from the patient’s initial assessment
3. The hospital does not permit restraint or seclusion for any other
purpose, such as coercion, discipline, convenience, or retaliation by staff.
Standard PC. 1270: A licensed independent practitioner orders the use of restraint or
seclusion.
Elements of Performance:
1. All restraint and seclusion are applied and continued pursuant to an
order by the licensed independent practitioner who is primarily
9

JCAHO is the national accrediting body for hospitals and other health care delivery organizations.
http://www.mlanet.org/resources/jcaho.html#Q1

11

responsible for the patient’s ongoing care, or his or her licensed
independent practitioner designee, or other licensed independent
practitioner.10
2. As soon as possible, but no longer than one hour after the initiation of
restraint or seclusion, qualified staff does the following:
-notifies and obtains an order from the licensed independent
practitioner
-consults with the licensed practitioner about the patients physical
and psychological condition
3. The licensed independent practitioner does the following:
-reviews with staff the physical and psychological status of the
patient
-supplies an order
Standard PC. 12.120: Clinical leaders are told of instances in which patients experience
extended or multiple episodes of restraint or seclusion
Elements of Performance:
1. The clinical leaders are immediately notified of any instances in which
a patient…experiences two or more separate episodes of restraint and/or
seclusion or any duration within 12 hours.
Standard PC.12.160: The patient and staff participate in a debriefing about the restraint
or seclusion.
Elements of Performance:
1. The patient and, if appropriate, the patients family participate with staff
members who were involved in the episode and who are available in a
debriefing about each episode of restraint or seclusion.
2. The debriefing occurs as soon as possible and appropriate, but no longer
than 24 hours after the episode.
3. The debriefing is used to do the following:
-Identify what led to the incident and what could have been
handled differently
-Ascertain that the patient’s physical well-being, psychological
comfort, and right to privacy were addressed
-Counsel the patient for any trauma that may have resulted from
the incident
-When indicated, modify the patient’s plan of care, treatment and
services
Fletcher Allen Health Care Internal Policy
Restraint and Seclusion: Behavioral Health/Psychiatric Emergency
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Because restrain and seclusion use is limited to emergencies (in which an independent licensed
practitioner may not be immediately available), the organization may authorize qualified trained staff
members who are not licensed independent practitioners to initiate restraint or seclusion before an order is
obtained from the licensed independent practitioner.

12

Definitions
Restraint: The direct application of physical force to an individual, without the
individual’s permission, to restrict his or her freedom of movement. The physical force
may be human mechanical devices or a combination thereof.11
Seclusion: Involuntary confinement of a person in a locked room or an area where a
patient is physically prevented from leaving.
Policy Statement
Because the use of seclusion and restraint have the potential to produce serious
consequences, such as physical and psychological harm, loss of dignity, violation of an
individuals rights, and even death, we will continually explore ways to prevent, reduce
and strive to eliminate the use of seclusion and restraint through effective performance
improvement initiatives.
The use of seclusion and restraint poses inherent risk to the physical safety and
psychological well being of the individual and staff. Therefore, seclusion and restraint
will only be used in an emergency, when an individual is at imminent risk of physically
harming herself/himself or others, and when non-physical interventions have not been
effective, or are not expected to be effective, in maintaining physical safety of the patient
and others.
The choice of seclusion or restraint will always be the least restrictive method possible
and based on the patients need.
Limiting the Use of Seclusion or Restraint to Emergencies
Non-Physical techniques are the preferred intervention in the management of behavior.
Such interventions may include redirecting the individuals focus, employing verbal deescalation, and the appropriate use of medication.
The organization does not permit use of seclusion or restraint for any other purpose such
as coercion discipline, convenience or retaliation by the staff.
Procedure

11

FAHC’s policy contains two definitions of restraint. The definition in the body of report is taken by
FAHC directly from JCAHO. The following definition also used by FAHC is taken from CMS: Any
manual method or physical or mechanical devices that restricts the freedom of movement or normal access
to ones body, material or equipment attached or adjacent to the patients body that he/she cannot easily
remove. Holding a patient in a manner that restricts his/her movement constitutes restraint for that patient.

13

Registered Nurse responsibilities immediately after initiating seclusion or restraint:
Inform the Resident/Physician of the need for a face to face assessment of the patient and
an order for seclusion or restraint.
Physician/Licensed Independent Practitioner responsibilities when a patient is in
seclusion or restraint:
-Assess the patient face to face immediately following the initiation of seclusion
or restraint
-Review with nursing staff the physical and psychological status of the individual
-Supply staff with guidance in identifying ways to help the individual regain
control in order for seclusion or restraint to be discontinued
-Within one hour of the initiation or seclusion or restraint, document the reason
for the use of seclusion or restraint, and write an order for the use of seclusion or
restraint
-Inform the attending physician of record or the physician covering for the
attending of record.
Within 24 hours after the episode of seclusion or restraint, those members of the staff
who were involved in the episode and who are present at the time, the patient, the
patient’s family (if appropriate), will participate in a debriefing about the episode of
seclusion or restraint
Evaluation and Care of Psychiatric Patients in the Emergency Room
Procedure
Patients will be asked to disrobe and will be offered a choice of hospital gown or
disposable clothing. If appropriate security staff will be called to assist as needed. (this
will eliminate the possibility of the patient retrieving a weapon, dangerous implement or
drugs from their clothing). NOTE: if disrobing is not an option due to potential traumatic
triggers or obvious escalating patient behavior, Security will be contacted to perform a
weapons pat down on the patient and remain with the patient.
Bathroom Options – the patient should never be left alone. Below are the options for use
of bathroom
a. Accompany the patient to the bathroom (this may require two staff members –
one inside the bathroom and one outside the bathroom to assist.)
b. Utilize a portable commode in patient’s room.
Modification of Aggressive Behavior (MOAB)
MOAB presents principles, techniques, and skills for recognizing, reducing, and
managing violent and aggressive behavior. In analyzing the MOAB techniques and other
efforts employed by SOs on August 6, 2006, VP&A consulted with MOAB trainer Glen
Doulette. Mr. Doulette has over ten years of experience working with psychiatric
patients in various hospital settings. He has trained in numerous behavioral intervention

14

programs and currently holds instructor level certificates in both MOAB and MANDT
(an alternative behavioral management system utilized in psychiatric facilities around the
country).
V. VERMONT PROTECTION & ADVOCACY’S FINDINGS
VP&A concludes that the FAHC E.D.’s care of RD on August 6, 2006 was deficient in
several material respects. These deficiencies resulted in unnecessary delay, distress,
trauma, and physical injury to RD. The following sections detail specific findings
supporting RD’s and VP&A’s concerns over his treatment.
A. Posting of Uniformed Guards
VP&A concludes that FAHC’s policy of posting uniformed guards outside the room of
patients experiencing acute paranoia and other delusional thinking is not best practice.
According to FAHC’s Psychiatric Resident, using uniformed guards as caretakers is not
ideal when dealing with a patient with delusional paranoia. This untrusting relationship
can lead to an increase in agitation level, which in turn can result in conflict.
FAHC and HCHS records clearly demonstrate that RD had long record of paranoid
ideations. In addition the record demonstrates that FAHC was or should have been aware
that RD suffered from delusions and paranoia. RD was a patient with a long-standing
and documented history of these symptoms. His most common and documented delusion
involved being followed by C.I.A. According to RD’s medical records he was currently
suffering from this paranoid delusion. RD’s August 4, 2006 FAHC E.D. records state
clearly that he “continues to have paranoid behavior.” (E.D. Physicians Summary,
8/4/06) FAHC records from August 6th further demonstrate that RD “has had anxiety and
been paranoid and had hallucinations and delusions.” (E.D. Nursing Summary, 8/6/06).
In an interview the Psychiatric Resident referred to RD as, “extremely paranoid
delusional…afraid of anyone who entered the room.”
Despite FAHC’s knowledge of RD’s paranoid state of mind and the impact that
uniformed SOs may have on a patient exhibiting paranoid behavior,12 FAHC relied on
uniformed SOs to manage RD’s behaviors. VP&A finds that FAHC disregarded known
risks of exacerbation that such a posting entailed. This disregard was a contributing
factor in elevating RD’s agitation level and ultimately resulted in the ensuing six
incidents of restraint.
B. Lack of Interaction with Mental Health Providers
VP&A concludes that mental health providers’ interactions with RD and the E.D. staff
were insufficient. According to the Psychiatric Resident, treatment of a patient should
12

Susan Stefan, “Emergency Department Treatment of the Psychiatric Patient (Oxford University Press
2006) p. 36 & 137 (describing the negative effects that uniformed security officers may have on
psychiatric patients).

15

not wait until the patient reaches a particular unit, rather treatment should begin when the
patient enters the hospital. Providers specializing in mental health are better suited to
treat an individual suffering acute mental illness than E.D. staff.
Mental healthcare providers’ interactions with RD and the FAHC E.D. staff during his
nine hours stay in the E.D. were inadequate. After admission RD was not seen by a
mental healthcare provider for one hour and thirty minutes. At this point RD was
evaluated by Crisis Evaluator #2. RD’s next contact with a mental healthcare provider
was with Psychiatric Resident. This interaction lasted for less than two minutes. A
formal evaluation did not take place until 5:35 p.m. This interaction was nearly six hours
and five restraints after admission to the E.D.
Although there were limited contacts between the E.D. and mental healthcare providers,
these contacts did not include guidance on dealing with a delusional patient. The contacts
were limited to medication requests on two occasions. Despite these requests, there is no
documentation suggesting that RD was offered medications. When asked, E.D. staff
indicated that treatment of patients with acute mental illness would benefit from better
communication between themselves and mental healthcare providers.
VP&A finds that because mental healthcare providers had inadequate contacts with both
RD and the E.D. staff, the E.D. operated on model based on detention rather than
treatment. This detention model at times disregarded RD’s psychological/ psychiatric
needs and was a contributing factor to the ensuing restraints.
C. Deviations From Requirements of CMS, JCAHO, FAHC’s Restraint Policy, and
MOAB
VP&A concludes that several of the physical restraints initiated upon RD were contrary
to standards set forth in the Center for Medicare and Medicaid’s Conditions of
Participation, the Joint Commission on Accreditation on Health Care Organizations,
FAHC Policy, and/or Management of Aggressive Behavior guidelines. The following
section will analyze the six restraints in accordance with the standards mentioned above.
VP&A considers each of the six incidents described as a restraint under CMS, JCAHO,
and FAHC’s internal policy because in each incident the SOs physically restricted RD’s
freedom of movement.
1st Restraint
During the first incident of restraint the SOs reacted to verbalizations made by RD. The
SOs describe RD’s behavior as “verbally abusive”, “cursing”, and in general bothersome.
The SOs’ attempts to negotiate with RD last for only one minute and ten seconds. After
being convinced verbally to return to his examination room, RD stopped at the doorway.
At this point he was immediately grabbed by two SOs and pushed into the room. After
being pushed into his room the SOs closed the door.

16

Threat of Harm and Least Restrictive Measures
During this incident VP&A finds that RD’s behavior did not rise to a level that would
justify the use of seclusion or restraint. According to CMS, JCAHO and FAHC’s internal
policy, restraint and seclusion are only justified if an individual is an imminent threat of
harm to themselves or others. Three of the four SOs present during this incident stated
that RD did not pose a threat of harm. One of the SOs explained that RD posed a threat
in that he stated he could leave the hospital if he wanted. VP&A finds that vague and
constant verbalizations, even of a desire to leave the hospital, do not constitute behaviors
that threaten imminent harm to self or others.
In addition to RD not being an imminent threat of harm to self or others, VP&A finds that
RD was restrained for improper purposes. According to CMS, JCAHO, and FAHC
policy, restraints cannot be imposed as a means of coercion, discipline, or convenience.
The SOs indicated that their reason in using force in order to keep RD in his room was to
comply with nursing staff’s direction. This justification for restraint and seclusion is
prohibited by CMS, JCAHO, and FAHC’s own policy.
In addition to the conclusion that force was not warranted by RD’s actions, least
restrictive measures were not attempted. According to CMS, JCAHO and FAHC policy,
restraint and seclusion may be implemented only when less restrictive measures have
been deemed ineffective. In this instance the SOs’ attempt at negotiation lasts for only
one minute and ten seconds. Despite the fact that negotiations appear to be successful, as
evidenced by the fact that RD is talked back to the doorway, once in the doorway the SOs
immediately apply force in placing RD on his bed. There is no evidence that the SOs or
other FAHC staff attempted to negotiate in order to avoid using force against RD once in
the doorway. This immediate use of force by the SOs, absent any indication that RD was
an imminent threat, demonstrates the SOs’ failure to attempt alternative methods prior to
implementing restraint and seclusion.
2nd Restraint
During the second incident of restraint RD was standing in the doorway speaking to SO
#2, while the other three guards were at the other end of the hallway. The SOs describe
RD as loud, abusive, and generally disruptive. RD denies the use of any vulgar or
abusive language. According to the SOs, the E.D. staff requested that RD be placed in
his room. The SOs attempted to talk with RD for one minute and twenty-two seconds
prior to applying force. At this point RD was shoved into his room. The SOs closed and
forcibly held the door shut.
Threat of Harm and Least Restrictive Measures
VP&A concludes that in this incident RD’s behavior did not rise to the level which would
justify the use of seclusion and/or restraints. Other than RD’s constant and vague
statements that he intended to leave the hospital, all four of the SOs interviewed did not

17

believe that he posed an imminent threat of harm to himself or others. As such restraint
and seclusion were applied contrary to CMS, JCAHO and FAHC policy.
In addition to RD not being a threat of harm to self or others, VP&A finds that RD was
restrained for improper purposes. The SOs stated that their use of force in this incident
was specifically to enforce the E.D. staff’s request that that RD be placed in his room.
This explanation leads to the conclusion that the restraint and seclusion were enacted as
means of coercion, discipline, and/or convenience, rather than to prevent imminent harm.
In addition to the conclusion that this restraint was not in response to an imminent threat
of harm, VP&A concludes that least restrictive measures were not attempted. In this
instance the SOs’ attempts at negotiation are brief. Negotiations last for only one minute
and twenty seconds. According to interviews with the SOs, the negotiations consisted of
little more than demanding that RD return to his room. VP&A finds that this short period
of negotiation with no evidence that alternatives were offered indicates a lack of
alternative solutions to physical restraint and thus a violation of the requirement that least
restrictive measures be attempted and deemed ineffective.
3rd Restraint
Just prior to the 3rd incident of restraint, RD was in the hallway bathroom. While in the
bathroom he pressed the call button and Nurse #2 responded. Upon arriving in the
bathroom Nurse #2 described RD’s behavior as “agitated”. RD stated to Nurse #2 that he
did not ring the call bell. In response Nurse #2 walked away from RD and out into the
hallway. According to the surveillance video and interviews with FAHC staff, RD
appeared to follow Nurse #2 down the hall.
In response the SOs initiated a restraint which resulted in RD being taken to the ground.
According to security an improvised technique was required due to the fact that RD had a
blanket wrapped around his shoulders. After the SOs gained control over RD, he was
lifted to his feet and escorted to his room. Prior to reaching RD’s room SO #1 stated that
RD was reaching for a pen. As a result RD was placed headfirst on the bed. He was held
down on the bed until the pen was removed.
FAHC Hospital Bathroom Policy for Psychiatric Patients in the E.D.
VP&A concludes that this restraint was implemented in part due to FAHC staff’s failure
to conform to hospital policy. According to FAHC hospital policy, a psychiatric patient
should never be left alone. Furthermore, policy dictates that when a patient uses the
bathroom, he/she should be accompanied by one or more FAHC staff or be provided a
portable commode. In this instance RD attended the bathroom without staff supervision.
This violation of policy clearly set the stage for the situation leading up to the ensuing
restraint.
Improper MOAB Technique

18

Towards the end of the restraint the guards placed RD’s legs in a scissor hold to
compensate for lower body movement. According to Mr. Doulette this hold is not taught
by MOAB and should not be applied or be necessary if MOAB technique is applied
correctly. MOAB teaches extending an individual’s arms beyond a 45-degree angle.
This technique ensures that the individuals applying a restraint are safely away from the
legs. Applying the scissor hold can lead to several negative consequences, including
compromising the knee joints as well as pressure on the abdomen which could place the
individual at a higher risk for asphyxia.
4th Restraint
The fourth restraint occurred approximately four and a half hours after RD’s admission
into FAHC. At nursing staff’s direction the SOs were asked to remove a bag of
medications that RD’s mother had brought into the examination room. After a brief
discussion with RD concerning handing over the medications, SO #3 escalated the
situation by approaching and attempting to grab the bag out of RD’s hand. At this point
RD stood up and moved to the corner of the room. The SOs followed RD to the corner of
the room and a physical restraint ensued. At some point during this restraint RD threw
his bag of medications. Even after RD had disposed of the medications the restraint
continued. RD was eventually taken down chest first onto his bed. At this point the SOs
searched RD for approximately three minutes.
Threat of Harm and Least Restrictive Measures
VP&A concludes that in this incident neither the presence of RD’s medications nor his
behavior justified the use of restraints. According to the witnesses to this incident RD did
not threaten to eat the medications. When asked what threat RD posed the SOs stated
that they did not believe that the medications posed a threat of harm. Furthermore, at the
time of the incident the fact that the SOs were posted outside of RD’s room and the fact
that RD’s mother was in his room made it extremely unlikely that RD would have been
able to harm himself by taking the medications. Due to the fact that no staff member
perceived an imminent threat and the unlikelihood that RD would have been able to harm
himself with the medications, even if he wanted to, VP&A concludes that RD’s
possession of the medications did not pose an imminent threat of harm to himself or
others.
VP&A finds that at no point following the SOs’ attempts to secure the medications did
RD pose a threat of harm to self or others. Two of the SOs felt that RD posed a threat of
harm during different points of this incident. The Lt. felt that RD’s position in the corner
by itself posed a threat of harm because it constituted a strategic advantage. SO #3 felt
that RD’s act of throwing the bag with his medications in it during the struggle rose to the
level of behavior that threatened imminent harm to the SOs. VP&A disagrees with the
SOs’ interpretations of RD’s threat levels in both instances.
VP&A concludes that once RD relieved himself of the medications the original purpose
behind the restraint had ended and so too should have any further restraints. According

19

to CMS, JCAHO and FAHC policy, once the threat of harm subsides so too should the
use of restraints. Contrary to this rule, FAHC staff continued to restrain RD. RD was
forced onto his bed and searched for a period of just under three minutes.
In addition to the conclusion that this restraint was not in response to a threat of harm,
VP&A also concludes that least restrictive measures were not attempted. In this instance
the SOs’ attempts at negotiation last for forty-two seconds prior to their attempting to
reach for the bag of medications. Forty-two seconds, without a threat of imminent harm,
is an insufficient amount of time to constitute an attempt at using least restrictive
measures. This limited amount of time is even more egregious considering that
alternatives, such as handing the medications to his mother, were suggested and not
properly explored. As a result of the extremely brief de-escalation period in conjunction
with the SOs’ failure to explore alternatives, VP&A finds that the SOs did not attempt
less restrictive alternatives in violation of CMS, JCAHO, and FAHC’s internal policy.
VP&A respects and acknowledges the logic in a policy aimed at preventing delusional or
suicidal patients from possessing their medications while being involuntarily detained in
the E.D. However in this case neither RD’s possession of medications nor his actions
posed a threat of imminent harm to self or other. At one point the basis for the restraint
had ended. Despite RD’s relinquishment of control of his medications the use of force
escalated. In the end RD was restrained for a period of just under three minutes. This
restraint was traumatizing for RD and was contrary to CMS, JCAHO standards and
FAHC policy.
Improper MOAB Technique
VP&A concludes that SOs deviated from MOAB in its restraint of RD. During this
incident SOs attempted to initiate a MOAB restraint and RD resisted. At various times
throughout the incident the four SOs positioned themselves on top of RD. While holding
RD in this position the SOs applied pressure to RD’s shoulder area. While pressure was
being applied, the SOs were holding RD’s arms behind his back. This position is
unnecessarily dangerous to a patient as it can put an individual at risk for positional
asphyxia. MOAB teaches an alternative prone position which involves the individual’s
arms being extended away from their body.
FAHC Disrobing and Search Policy for Psychiatric Patients in the E.D.
VP&A concludes that the search which resulted from the restraint was contrary to FAHC
policy. According to FAHC policy a psychiatric patient is required to disrobe upon
admission in the E.D. FAHC policy goes on to state that, “[i]f disrobing is not an option
due to potential traumatic triggers or obvious escalating patient behavior, Security will be
contacted to perform a weapons pat down on the patient and remain with the patient.”
RD was not required to disrobe upon admission. According to the E.D. Nurse this
decision was made due to RD’s agitated behavior. Although the SOs were called to
guard RD, they did not conduct the required search. Such a search may have alleviated
any need to conduct the search which occurred during this incident. VP&A believes that

20

this search was conducted at an inopportune time and resulted in unnecessary trauma to
RD.
5th Restraint
The fifth incident of restraint occurred approximately seven hours after RD’s admission
into FAHC. Prior to this restraint the SOs had been relieved of their duty to remain with
RD. The EMT gave RD permission to sit in a chair in the hallway. Several minutes after
taking his seat, RD stood up from his chair and headed towards the E.D. exit. The SOs
met RD at the exit and escorted him back to his room via resistive escort. This restraint
was not captured on surveillance video.
Inconsistent Application of Policy
VP&A concludes that this restraint was partially the result of FAHC’s inconsistent
application of its internal policies. During VP&A’s interviews with FAHC employees,
all interviewees questioned stated that that the general policy is to restrict all patients to
their respective rooms. Despite this policy, at different times and at the will of different
individuals RD was given permission to leave his room. These inconsistencies may have
led to RD being confused about his ability to leave his room. At one point RD was
allowed to leave his room and interact with E.D. staff. At other points he was being
forcefully placed in his room by the same staff. VP&A does not advocate for a policy
which restricts patients to their room (especially if they are being held in the E.D. for
lengthy periods); however VP&A does believe that all FAHC policies should be
consistent so that patients know what to expect. VP&A concludes that inconsistent
policy enforcement that RD was exposed may have led to confusion which ultimately
resulted in this and other episodes of restraint.
6th Restraint
The sixth incident of restraint occurred just prior to RD’s transfer to Shepardson Six. RD
was seated at the nursing station at the end of the hallway. Approximately seventeen
minutes prior to the restraint, a clerk from admission presented RD with a pen and
admission paper work. Upon presentation of the admission paperwork RD became
agitated and according to reports began speaking loudly. Between the time RD was
presented with the registration paperwork until just before the restraint there were up to
six people surrounding RD. These people included the EMT, RD’s parents, and
eventually three SOs.
Upon approaching the SOs requested that RD lower his voice. At some point the SOs
identified that RD was holding a pen in a threatening manner. Due to this perception the
Lt. attempted to gain control RD’s left arm. At the same time SOs #1 and #2 initiated a
resistive escort. Shortly thereafter Lt. ordered that handcuffs be applied to RD. As the
SOs attempted to apply the handcuffs, RD broke free of the escort hold. In an attempt to
subdue RD, the SOs took him to the ground. During the takedown Lt. held RD around
the neck. Upon hitting the ground RD nearly hit his head on a laundry basket in the

21

middle of the floor. After a brief struggle on the floor, RD was handcuffed and escorted
by the SOs to Shepardson Six.
Interaction with Admission Clerk
VP&A concludes that the admission clerk’s contact with RD resulted in increasing his
agitation level which contributed to this incident of restraint. According to 42 CFR
482.13(f)(6), “all staff who have direct patient contact must have ongoing education and
training in the proper and safe use of seclusion and restraint application and techniques
and alternative methods for handling behavior, symptoms, and situations that traditionally
have been treated through the use of restraints or seclusion.” According to information
received from FAHC Risk Management, the admission clerk did not have proper training
in the use of restraint and seclusion or techniques and alternative methods for handling
behavior, symptoms, and situations that traditionally have been treated through the use of
restraints or seclusion. Such training would likely have had a significant impact on how
this clerk approached and interacted with RD. As a result of his contact with the
admission clerk RD’s agitation level rose and the situation ended in restraint.
Staff Supplying RD with a Pen
VP&A concludes that FAHC’s negligence in providing RD with a pen was a direct cause
of this restraint. RD’s possession of a pen had directly led to a prolonged restraint earlier
in the day. Despite this FAHC staff provided RD with a pen. According to the Lt. this
restraint was initiated due the threatening manner in which he perceived RD to be holding
the pen. VP&A suggests that providing RD with a pen given his specific situation was
unacceptable and in this instance directly led to the ensuing struggle and subsequent
restraint.
Failure of Security to Use adequate De-escalation Techniques
VP&A concludes that prior to this incident of restraint least restrictive measures were not
attempted. In this instance the SOs’ attempts at negotiation last for only two minutes and
five seconds prior to initiating restraints. In addition to this short period of time the SOs’
de-escalation techniques were ineffective. According to interviews and reports the SOs’
presence was in response to complaints, by other patients, of foul and loud language. The
SOs’ attempts at de-escalation appear to be limited to attempts at quieting RD down and
encouraging him to go to the psychiatric unit. While both the records and interviews
identified RD’s confusion over the requirements of the paperwork as being obvious at the
time, neither source indicates any effort was made to engage RD about those concerns as
part of the de-escalation process. In addition to ineffective de-escalation techniques RD
alleges that one of the SOs engaged in improper behavior. According to RD an SOs
stated, “your going to be in the hospital for a long time.”
Improper MOAB Technique

22

VP&A concludes that several of the techniques used during this restraint were not
MOAB compliant. First, prior to initiating contact with RD, staff should have removed
potentially dangerous objects from the area (i.e. laundry container). By not clearing the
area RD was subject to unnecessary risk of injury. Next, the SOs’ positioning gave the
appearance of cornering RD. According to Mr. Doulette, cornering a psychiatric patient
can lead to an increase in a patient’s agitation level. Third, while in the process of taking
RD to the ground the SOs should have let go of at least on of his arms so that he could
protect his head. This safety measure is explicitly taught by MOAB. Failing to release
patient’s arms again exposes a patient to unnecessary risk of injury. Fourth, one of the
guards applied a headlock hold. This hold is not taught nor recommended by MOAB due
to the unnecessary risk of injury that could be inflicted on a patient. Finally, RD’s legs
were again placed in a scissor hold. This technique is not taught by MOAB and can lead
to unnecessary damage to the knee joints and places pressure on the abdomen which
could place the individual at a higher risk for asphyxia.
Use of Handcuffs
VP&A concludes that the use of handcuffs on any patient in any hospital setting by a
hospital staff member is contrary to standards regulating hospitals participating in
Medicaid and Medicare programs. According to CMS’s interpretive guidelines,
“handcuffs; manacles; shackles; and other chain type devices are considered law
enforcement restraint devices and would not be considered safe appropriate health care
restraint interventions for use by hospital staff to restrain patients in hospitals.” RD was
handcuffed and escorted through the hospital by FAHC employed SOs. This clearly
demoralizing treatment is directly addressed and prohibited by the interpretive guidelines.
D. Failure to Comply with Procedural Requirements
FAHC policy uses both CMS and JCAHO’s definition of restraint. In both of those
definitions application of manual force is considered a restraint if it restricts an
individuals access to one’s body. FAHC’s policy is more precise in that it states that
“holding a patient in a manner that restricts his/her movement constitutes restraint for that
patient.”
When a restraint is applied, several procedural requirements are triggered under CMS,
JCAHO and FAHC policy. VP&A finds that FAHC disregarded several of these
requirements in each incident of restraint.
Restraint Order
VP&A concludes that during each incident of restraint FAHC E.D. staff failed to obtain
an order of restraint from the treating physician. According to JCAHO, standard PC.
1270, a licensed practitioner must order the use of restraint or seclusion. The authors of
JCAHO recognized the impractical nature of obtaining an order prior to seclusion or
restraints in emergency situations. As such according to a footnote to PC. 1270, “the
organization may authorize qualified trained staff members who are not licensed

23

independent practitioners to initiate restraint or seclusion before an order is obtained from
the licensed independent practitioner.” Despite the fact that a restraint may be initiated
without an order, JCAHO requires that as soon as possible, but no longer than an hour
after the initiation of a restraint a qualified staff member must obtain an order from the
licensed independent practitioner.
On August 6, 2006, RD was subjected to several manual interventions, which would
qualify as restraints under CMS, JCAHO and FAHC policy. The restraints were carried
out by the SOs either at their own will or at the will of the nursing staff. There is no
indication that either the SOs or the nursing staffs are practitioner designees. Even
assuming the SOs and nursing staff were considered practitioner designees, VP&A finds
that there is no indication in FAHC records of the required order from a licensed
independent practitioner.
Consultation with Licensed Practitioner/Treating Physician
VP&A concludes that contrary to law and policy FAHC E.D. staff failed to consult a
licensed practitioner/treating physician after the initiation of restraint. CMS, JCAHO and
FAHC policy require that a treating physician/licensed practitioner be consulted as soon
as possible after a restraint is initiated. JCAHO requires that this consultation occur
within one hour of the restraint and that the licensed practitioner review with the staff the
physical and psychological status of the patient. Despite these requirements VP&A
found no indication in the records that either a treating physician or a licensed
practitioner was consulted. VP&A’s interview with FAHC E.D. staff confirmed this
finding. Staff members interviewed indicated that there were no meaningful contacts
between themselves and qualified mental health staff regarding each incident of restraint.
Furthermore, many of the interviewee’s felt that they could benefit from increased
contacts and guidance from mental healthcare providers. Consultations between staff and
a licensed practitioner could have proved meaningful in helping staff to deal with RD’s
mental state and related disruptive behaviors.
Face to Face Evaluation
VP&A concludes that FAHC violated internal policy by not having a physician conduct
an immediate face to face evaluation with RD after each incident of restraint. According
to FAHC policy after initiating a restraint a registered nurse must inform a resident or
physician of the need for a face to face evaluation of the patient. There is no indication in
the records that after the restraints a nurse informed a resident or physician of the need
for a face to face evaluation. FAHC Resident The Psychiatric Resident and P.A. #2 each
indicated that they were not even aware that several of the incidents of restraint had
occurred.
Multiple Restraint Requirements
Contrary to JCAHO standards, FAHC E.D. staff failed to notify clinical leaders regarding
the reoccurring restraints. According to standard PC. 12.120 clinical leaders must be

24

immediately notified when a patient experiences two or more episodes of restraint within
a twelve-hour period. RD experienced six episodes of restraint within a nine-hour period.
Despite this there was no indication in the records that clinical leaders were notified
Debriefing
There is no record in FAHC’s files indicating that any debriefing took place. According
to both JCAHO and FAHC policy a debriefing must occur within 24 hours of an episode
of seclusion or restraint. That debriefing must include the members of the staff who were
involved in the episode, the patient, and the patients’ family (if appropriate). Finally the
debriefing’s purpose is to identify what led to the incident and what could have been
handled differently, counsel the patient for trauma, and to ascertain the patient’s well
being and psychological comfort.
RD was subjected to six episodes of restraint, each of which met CMS, JCAHO, and
FAHC’s definition of restraint. After RD was escorted to Shepardson Six there was a
meeting between the Hospital Supervisor, RD’s parents and the Lt. For two reasons this
meeting did not comply with the requirement for a debriefing as intended by JCAHO.
First, several of the attendants required by FAHC policy were not present. Missing from
the meeting was RD and a majority of the staff members involved in the restraint.
Second, the purpose of the meeting was to address RD’s parents concerns and not to
analyze the restraint.
E.Documentation
VP&A finds FAHC staff’s documentation to be inadequate in several instances. First,
FAHC staff failed to document injuries inflicted on RD during his stay. On August 8,
2006, a VP&A advocate visited with RD on the inpatient psychiatric unit. During this
visit it was noted that RD had sustained several bruises on his wrists and upper arms.
Despite the presence of bruising our advocate found no documentation of these injuries in
either the E.D. or inpatient psychiatric records.
Second, the E.D. staff’s documentation surrounding medication orders is unclear. In its
review of this incident Vermont Protection& Advocacy could not decipher when
medications were ordered, if and when they were administered, and if not, why.
Furthermore, FAHC E.D. staff members, in their interviews with VP&A, were unable to
clarify these issues. While VP&A does not advocate for the application of involuntary
medications, we do advocate for clear and complete documentation when they are
considered and ordered.
Finally, E.D. staff failed to appropriately document instances of restraint. There is no
mention in the medical records, other than the incident reports, of four of the six
restraints. Furthermore, there is not mention in any of the records of the first two
restraints. In each of the first two incidents RD was shoved into his room while in his
doorway. Without the security surveillance there would be no record of these incidents.

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F.Peer Review Process
REDACTED. Pursuant to federal law and a consistent agreement with FAHC, VP&A
cannot comment on any peer review process that FAHC may have engaged in regarding
the incidents relevant to this report. In the event such review occurred, VP&A would use
this section to communicate our findings regarding that process to FAHC as permitted
under both the federal law and our agreement with FAHC.
VI. CONCLUSION
After a thorough investigation of RD’s August, 6 2006 E.D. stay, VP&A concludes that
FAHC violated: Internal Policy, JCAHO Accreditation Standards, CMS Conditions of
Participation, and MOAB Protocol. The above violations resulted in both physical injury
and trauma to RD. The remainder of this report will provide recommendations aimed at
preventing injury to future patients with mental illness who visit the FAHC E.D. We
strongly suggest that FAHC administration review and establish time periods within
which to implement these recommendations.
.
VII. RECOMMENDATIONS
1) Develop capacity to use staff other than uniformed security officers to monitor and
interact with patients suffering from acute mental illness in the E.D. Develop and
implement policies describing utilization of such resources.
2) Change the E.D. model for psychiatric patients from a detention based model to
treatment based model. This change would require more interactions between mental
health staff and patients and increased contacts between the E.D. staff and psychiatry
and/or mental health care practitioners.
3) Additional and intensified training for security officers on legal standards regarding
restraint and seclusion. This training should provide staff with: 1) an understanding of
the legal definition of a restraint and seclusion, 2) an understanding of when restraint
and/or seclusion may be implemented, 3) the requirement of using least restrictive
measures, and 4) an understanding of the importance of de-escalation techniques in this
process.
4) Additional and intensified training for all relevant staff on the procedural legal
requirements triggered after restraint and or seclusion is implemented (Physician’s order,
consultation, face to face evaluation, and debriefing).
5) Additional and intensified training for all relevant FAHC (i.e. security officers, nurses,
physicians, and “sitters”) staff on ED Policies (bathroom policy, search policy).

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6) Create a new training curriculum and adequately train on a policy that restricts
agitated psychiatric patients access to pens or other items that could be perceived as a
weapon and justify initiating restraint.
7) Stress with staff the importance of consistency of policy application (room restriction
policy).
8) Re-training of all relevant staff in behavioral management techniques. Preferably in a
system that furthers the goal of a seclusion and restraint free environment.
9) Immediately cease the use of handcuffs/shackles/leg irons on patients.
10) Make sure that all FAHC employees who have contact with a patient suffering from
an acute mental illness have training in the proper and safe use of seclusion and restraint
application and techniques and alternative methods for handling behavior, symptoms, and
situations that traditionally have been treated through the use of restraints or seclusion
11) REDACTED.
12) Overall improvements in documentation. VP&A recommends that the importance of
accurate and detailed documentation be discussed and improvements be assured by
review, perhaps by an outside entity engaged specifically for that purpose.
13) Review, and revise as necessary, all ED policies and procedures to deliver services
that are sensitive and responsive to the needs of trauma survivors. An effort should be
made to reduce or eliminate any potentially re-traumatizing practices such as restraint/
seclusion and involuntary medication. One way this can be accomplished is by creating
an individualized de-escalation plan to identify triggers, warning signs, and behavioral
strategies.
14) Written apology to RD and his parents for the mistakes and missed opportunities
apparent in FAHC’s treatment of him on August 6, 2006 and the subsequent distress and
difficulties those incidents have caused and may continue to cause him in the future.

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