Allegations that physical and chemical restraints were being used at two Boys Town facilities near the Omaha headquarters campus resulted in the state of Nebraska halting all referrals to the two facilities – both of which are for youths with severe behavioral and emotional problems – and the suspension continues despite ongoing negotiations.
Nebraska officials said such a hold on referrals was apparently unprecedented in the state.
The allegations arose after Magellan Health Services, Nebraska’s contractor that handles its Medicaid and Medicare claims, sought a review of the two facilities, the Boys Town Intensive Residential Treatment Center (RTC) –used for extremely troubled youths – and the Specialized Treatment Group Homes (TGH), for youths with less intense but still severe mental health problems.
Those surveys, conducted in May and July, led to the halt order, issued Aug. 26. Allegations at RTC include strapping youths face down on a gurney – using three safety belts – so they can be placed in isolation. Interviews with patients found that youths were injured during this procedure, including a girl nearly choking herself to death with a hair tie while in seclusion. Another violation involved keeping youths in seclusion after an emergency safety situation had ended, contrary to federal law. RTC was also cited for using chemical restraints – psychotropic medications – 19 times, including using three of the potent drugs on one patient.
The allegations at TGH include not having medical personnel check youths for injuries immediately after they had been restrained, and not having orders from a nurse or physician to use the physical restraints. There were also documentation breaches at both facilities.
Other U.S. facilities’ problems
Boys Town policies forbid the use of mechanical restraints – or any device to restrict movement that cannot easily be removed – on any patients.
Reports of using drugs to calm patients were disputed by RTC’s program director, Dennis Vollmer, who said the surveyor misquoted him and that RTC has never used drugs for that purpose. His proposed corrections of the various problems are more training for staff, especially on documentation, and for staff to “continue to provide safe services to kids.”
Those solutions have not been acceptable to Magellan, which is asking for additional information and plans for resolution. State agencies have agreed to Boys Town’s corrective proposals.
The use of restraints, especially to keep youths in a facedown position, has resulted in deaths at other facilities, some of which have lost their licenses to operate because of those actions. Several states have outlawed the use of such restraints.
In April, a similar type of youth RTC in Charlotte, N.C. – The Keys of Carolina – almost lost its state operating license, in part because of excessive force by staff documented in a similar review. In June, Friends Hospital lost its license to provide Medicaid-covered care to Philadelphia area low-income psychiatric patients after a review, also by Magellan Health Services, found inadequate staffing levels and patient overcrowding. The license was restored in August.
Others involved in mental health advocacy maintain RTCs and TGHs are never the solution, regardless of whether they violate policies. The Washington, D.C.-based Bazelon Center for Mental Health Law, for instance, writes on its website, “Children with even the most severe mental disorders can live at home, achieve in school and flourish as adults. What they need to succeed are supportive services that are provided primarily in the family’s home and community settings.”
Though many of the violations at the Boys Town facilities focused on failed safety measures, Vollmer went on to indicate that the only major change he wants to see in his staff is improved documentation habits.
With four locations, TGH has a total of 55 beds and RTC has 47 beds. Both programs – which serve youth ranging from 7 to 18 years old – formerly received a majority of their residents from state referrals but they are now at full occupancy, with waiting lists, because of large numbers of private placements, juvenile justice placements and out-of-state resident patients.
The violations
This is a more detailed list of the documented violations and the plans of correction.
At RTC:
• Violation: Use of both chemical and mechanical restraints, even though RTC’s existing policy prohibits mechanical restraints and does not even address chemical ones. Survey found evidence of a use of a gurney to transport youth into a seclusion room. “The youth is placed prone, face down onto the gurney, and the three seat belts are buckled over the body parts. … Employees hold the youth’s legs and arms while the youth is rolled to the seclusion room.” As for chemical restraints, an interview with a program director found the use of 19 chemical restraints last year, including using three psychotropic medications on one resident, out of 18 total Emergency Safety Interventions (ESI) for RTC.
Plan of Correction: Modified policy to remove all safety belts on gurneys and re-educate staff on this matter. Policy also amended to include prohibition of chemical restraints.
• Violation: Failure to uphold standard of not using restraint and seclusion to result in harm or injury to the resident. Interviews with clients showed they did sustain injuries during this process.
Plan of Correction: Re-educate all direct care staff to ensure they conduct more thorough safety searches before the youth enters a seclusion room.
• Violation: Failure to uphold standard of ensuring the safety of the resident or others during an emergency safety situation, as evidenced by the use of a safety hold and/or seclusion that did not exclusively occur when there was imminent risk of danger.
Plan of Correction: Program director meeting with staff to emphasize other least restrictive alternatives, such as “providing additional space, time away, redirection, caring gestures, prompting, proper implementation of time-out procedures, encouraging self-control and possibly removing other youth from the environment to assist in calming the child.” The plan of correction also includes modifying policies to further emphasize use of least restrictive interventions.
• Violation: Failure to ensure clients were released from seclusion immediately upon cessation of the ESI.
Plan of Correction: Acknowledgement that although it was previous policy to release a youth from the seclusion room as soon as possible, the review shows this policy has not been consistent with practice. Re-educate staff, focusing on such measures as use of instant communication devices by staff members and prompt response of nurses to all ESI calls.
At TGH –
• Violation: Failure to ensure that a written certification of need for service had been completed within 14 days of admission for three of four sampled clients.
Plan of Correction: Explanation that the three clients mentioned all had pre-existing certificate of need charts from their previous placement at RTC and that when they were transferred from RTC to TGH the administrator – new to his position – failed to ensure a new certificate of need. The plan of correction calls for additional training for this administrator and all staff responsible for chart reviews.
• Violation: The standard for restraint and seclusion policy for the protection of residents was not met, in that a state employee is not required to evaluate the resident immediately after the restraint is removed. A review of the TGH policy showed no specification to do this immediately. The program director said it was thought that they had an hour to complete the assignment.
Plan of Correction: Amending policy to require employees to conduct the evaluation immediately afterward, rather than as soon as possible but no more than an hour afterward, which was the previous policy.
• Violation: Failure to require verbal orders from qualified personnel before restraints take place. The policy allows physicians to issue restraint orders after restraints have taken place.
Plan of Correction: Modifying procedures to emphasize immediate notification to a registered nurse once a hold has been initiated. Completion of staff training by Sept. 25, 2010, regarding changes in the notification process for a safety hold, and specifically retraining of registered nurses on their responsibility to immediately notify a physician.
• Violation: Failure to keep on file a written hospital transfer agreement, which ensures the accepting facility agrees to admit the youth without condition.
Plan of Correction: Propose a new signed and executed transfer agreement.
