On March 13, 2013, police officers escorted Alex, 26, to the emergency department of a hospital in Springfield, Vermont, after he threw a chair at a staff member of an outpatient mental health facility nearby.
But when he arrived, emergency department medical staffers treated him more like a criminal than a patient, a review of public records shows. Federal hospital inspection reports from the Centers for Medicaid and Medicare Services, the agency that administers those programs, offer an account of the incident. (Al Jazeera has chosen not to publish Alex’s full name out of respect for the patient.)
In the waiting room, Alex complained of anxiety and depression stemming from a diagnosis of schizophrenia. A nurse’s clinical report stated that before his arrival, he was having trouble sleeping and was feeling confused.
Approximately three hours later, nurses shouted for the police when Alex grabbed the collar of a security guard, according to an account of the incident by a physician’s assistant on duty at the time.
The physician’s assistant, who was not named in the incident report, helped restrain Alex in order to calm him. Despite being at a hospital emergency room, he was never checked to determine if he should receive emergency care — a violation of federal law — an inspection later found. Staffers, along with a nurse manager, instead decided to press charges and send the patient to jail.
Springfield police records confirmed that he was charged with disorderly conduct and assault.
A Windsor County judge refused to incarcerate Alex and ordered that he return to the hospital for evaluation. This time, after being screened, medical staffers determined that he required hospitalization to treat an acute schizophrenic attack.
Paul Gionfriddo, the CEO of Mental Health America, a nonprofit that promotes mental health and prevention services for mental disorders, condemned the actions of Springfield Hospital. “They were not doing their job,” he said.
Federal law requires hospitals to treat patients in need of emergency care. But there are consistent cases across the country of patient dumping of the mentally ill.
In 2012, Duke University Hospital was fined $180,000 for failing to accept five transfers of unstable patients, and in 2013, Carolinas Medical Center in North Carolina was fined for failing to provide stabilizing treatment for a psychiatric patient. Last year a psychiatric hospital in Las Vegas was caught busing mental health patients out of state.
“The treatment of mental illness is and has been an unwanted child in the American health system,” said Susan Preston, a lawyer, in testimony before the U.S. Commission on Civil Rights on patient dumping cases last year.
Still, it is highly unusual for a hospital to call police and press charges against patients.
Gionfriddo acknowledged that across the country, the stigma of mental health problems, behaviors associated with episodes and a lack of proper training prevent some health care professionals from properly treating patients manifesting mental health problems.
“We’ve just stopped thinking about these as simply health conditions because we’re paying so much attention to these behavioral manifestations and we don’t treat the condition,” he said. “We don’t think about treating them as the same kind of a challenge we would as a cancer patient who was in a crisis.”
While the circumstances of Alex’s arrest stand out, it is increasingly common for the mentally ill to end up incarcerated. There are 10 times the number of mental health patients in U.S. prisons and jails as in state psychiatric hospitals, according to a 2014 report from the Treatment Advocacy Center, a nonprofit dedicated to eliminating barriers to mental health treatment. Criticism of treatment of mentally ill inmates has sharpened in the last year, after reports of conditions in New York and Florida correctional facilities.
Police departments in cities like Memphis, Tennessee, and San Antonio have implemented reforms, creating crisis intervention teams to better respond to problems involving the mentally ill.
For improperly handling Alex’s care, Springfield Hospital was sanctioned. In September 2013 the Department of Health and Human Services fined Springfield, a nonprofit hospital, $50,000 for violations of patient care related to that incident and a similar one a week earlier, in which the hospital pressed charges against a patient having a bipolar episode, a settlement order shows. Under federal law, $25,000 is the maximum fine that a hospital with fewer than 100 beds — like Springfield — may be charged for each violation.
Alex could not be located for this story, despite calls to state mental health facilities and communication with members of his immediate family.
Springfield Hospital said it was not able to comment on particular patient events. In an email, the hospital’s chief of communications, Anna Smith said, “Patient care and safety are always paramount.”
“We have worked hard with our staff, representatives of the Vermont Department of Mental Health and others to train and provide as many resources as possible in our emergency department, in the best interest of our patients, staff and public safety,” she said.
Mental health advocates say the arrests are symptomatic of a larger problem plaguing hospitals throughout Vermont: a lack of resources to properly treat mental health patients since the state mental hospital closed several years ago.
While Springfield hospital workers who spoke to Al Jazeera America agree that the situation is not ideal, they say law enforcement is sometimes necessary to maintain a safe environment for patients and staffers.
But records and interviews reveal that the 2013 incidents at Springfield Hospital are not isolated cases and that the facility has for years used questionable tactics to treat its mental health patients.
Vermont’s mental health system was badly strained in 2011 when the state psychiatric hospital closed because of damage by Tropical Storm Irene. That meant the loss of 54 beds available for patients who need inpatient psychiatric treatment.
The shortage has led to an increase in mental health patients who may remain in emergency departments for long periods, said Jack McCullough, the director of Vermont Legal Aid’s Mental Health Law Project.
General hospitals simply don’t have the resources to deal with such patients, he said. Often emergency departments do not have separate psychiatric wards, and there may be no specialists on staff trained to deal with these patients, who may be violent or unruly.
The influx of mental patients has led some hospitals in the state, including Springfield, to designate several rooms for psychiatric holds of patients who are guarded by sheriffs.
Many hospitals in Vermont now rely on partnerships with law enforcement to handle the influx of high-risk patients after the closure of the state hospital, said Jill Olson, the vice president of policy and legislative affairs for the Vermont Hospital Association.
“A few patients present a very high, very immediate risk to their own safety or the safety of staff and other patients,” she said. “While the role of law enforcement is strictly limited by the federal regulations that govern hospitals, our members do rely on Vermont sheriffs to stay with the most violent patients in the emergency department, in the interest of safety.”
But McCullough challenged these tactics.
“Patients are not really receiving any treatment when they’re there,” he said. He added that patients are essentially “just locked up in a tiny room,” sometimes for as long as several weeks.
According to budget reports submitted to the state by the hospital, the problem significantly worsened at Springfield from October 2012 to September 2013. In that time, the number of mental health patients held in the emergency department for long periods spiked. One report pointed to area residents’ challenges with poverty, low education and drug use as contributing to the hospital’s strain.
The town of Springfield has a population of just under 10,000. Its 25-bed critical access hospital is the smallest in the state and has the highest percentage of Medicare and Medicaid patients.
The Windsor County Sheriff’s Department confirmed that it sends deputy sheriffs to the hospital to assist with supervision of patients having mental health issues.
“We’re just there to make sure that everything is OK and there’s no problems,” said Sheriff Michael Chamberlain. “Basically, we’re just there to assist with security.”
He said that the partnership began a few years ago and that his department receives training from the Department of Mental Health on how to handle patients. The biggest problem, he said, is that it does not always have the resources to respond to every call from the hospital.
The state has made progress to recover the number of beds for mental health patients. Just a few months ago, the Vermont Psychiatric Care Hospital opened in the town of Berlin, about an hour and a half from Springfield, and the state has expanded the number of voluntary treatment beds in other facilities.
“There’s definitely stumbling blocks,” said Frank Reed, the deputy commissioner of Vermont’s Department of Health, in response to questions about violations in care at Springfield Hospital’s emergency department.
“Considering it’s only been 1,285 days since the state hospital closed, we’ve made a tremendous amount of progress in that time,” he said of efforts to expand the number of beds.
Pamela Cipriano, the president of the American Nurses Association — a group that represents registered nurses — said it is critical that hospitals take the initiative to prevent workplace violence and ensure the safety of health care workers and patients.
“We must completely dispel the notion prevalent in too many health care organizations and held by too many health care workers and leaders that being physically or verbally assaulted is just part of the job,” she said.
While the 2013 arrests of its patients may be the most extreme treatment of its mentally unstable patients, federal hospital inspection reports show that Springfield has continued to violate standards in its treatment of mental health patients.
In an inspection report from last July, federal regulators found that a mental health patient was restrained to coerce to take anti-psychotic medication. When he refused to take the pills, he was restrained overnight. Only after more than 12 hours — and urinating on himself while restrained — was he released.
The incident violated state laws regarding patient care, according to the inspection report.
Springfield Hospital is one of 16 hospitals in Vermont. Since 2013 it has been cited 32 times by federal regulators, including six times for violations of local, state or federal patient care laws. In that time, only Brattleboro Retreat, one of the state’s inpatient mental care facilities, has been cited for more violations.