Afice

VERMONT

AGENCY OF HUMAN SERVICES
DEPARTMENT OF DISABILITIES, AGING AND INDEPENDENT LIVING

Division of Licensing and Protection
103 South Main Street, Ladd Hall
Waterbury, VT 05671-2306
http://www.dail.vermont.gov
Voice/TTY(802) 871-3317
To Report Adult Abuse: (800) 564-1612
Fax (802) 871-3318
August 19, 2014

Mr. Timothy Ford,
Springfield Hospital
Po Box 2003
Springfield, VT 05156-2003

Dear Mr. Ford:
Enclosed is a copy of your acceptable plans of correction for the survey conducted on July 8,
2014. Please post this document in a prominent place in your facility.
We may follow-up to verify that substantial compliance has been achieved and maintained. tf we
find that your facility has failed to achieve or maintain substantial compliance, remedies may be
imposed.
Sincerely,

/0.44/24

enit,

Frances L. Keeler, RN, MSN, DBA
State Survey Agency Director
Assistant Division Director
FK:jl

Disability and Aging Services
Licensing and Protection

Blind and Visually Impaired
Vocational Rehabilitation

 RECEIVED
Division of
AUG 11 14

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

Licensing aria
Protection

2) MULTIPLE CONSTRUCTION

(X1) PROVIDERISUPPLIER/CLIA
IDENTIFICATION NUMBER:

A. BUILDING

PRINTED, 07/2877014
FORM APPROVED
OMB NO. 0938-0391
(X3) DATE SURVEY
COMPLETED
C

471306

B. WING
STREET ADDRESS, CITY, STATE, ZIP CODE

NAME OF PROVIDER OR SUPPLIER

PO BOX 2003

SPRINGFIELD HOSPITAL
(X4) ID
PREFIX
TAG

07108/2014

SPRINGFIELD, VT 05156

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFiciEN0Y)

PREF X
TAG

COMPLETI
DATE

000

C 000 INITIAL COMMENTS
An unannounced on-site investigation of this self ,
report was conducted by the Division of Licensing
and Protection on 7/7 - 7/8/14, There were no
violations identified regarding the self report,
however there were violations regarding inpatient
treatment and restraint use,
C 152 485.608(b) COMPLIANCE W ST & LOC LAWS &
REGULATIONS

Right to Respect and Dignity; Right to Refuse

C 152

All patient care services are furnished in
accordance with applicable State and local law
and regulations.

Treatment to the extent permitted by law
All Staff and Physicians will review and sign off on the

08 22 14

Restraint and Seclusion Policy and the Vermont
Department of Mental Health restraint
requirements. A written physician order to continue
restraint will be provided each 4 hours during
duration of restraint use. Patient will be immediately
removed from restraint once physician provides

This STANDARD is not met as evidenced by:
Based on staff interview and record review,
during the provision of care and services staff
failed to maintain patient rights in accordance
with State statute, Title 18, Chapter 42; Bill of
Rights for Hospital Patients; § 1852, 1) The
patient has the right to considerate and respectful
care at all times and under all circumstances with
recognition of his or her personal dignity, and §
1852. 5) The patient has the right to refuse
treatment to the extent permitted by law, for 1 of 3
applicable patients (Patient #1),
Findings include:
Per record review staff failed to provide care 'in a
respectful and dignified manner by failing to
adhere to the CAH's policy for restraint use.
Per record review the policy, titled Restraint and
Seclusion Policy last approved on 4/7/14 states
"...Restraint and seclusion will not be used as a
means of coercion, discipline, convenience or
retaliation by staff ... It is our responsibility to
facilitate the discontinuation of restraint or
seclusion as soon as possible...we are committed
_ABORATORY DIRECTOR'S OR PROVIDER

order for restraint removal. Coercion will not be
utilized to facilitate restraint removal.
Education:
Staff will be educated to methods of potential

09 05 14

coercion with attention to use of medications,
smoking, and toileting as potential methods of
coercion. Therapeutic alternatives based upon
patient assessment will be considered prior to
implementation of any restrictive restraint. These
include comfort measures, activity diversion
measures and psychosocia I measures.
Monitoring:
Behavior flow sheets will be reviewed to assess
documentation of appropriate assessments,
implementation of appropriate interventions and
treatment outcomes. Any deviation from policy will
be reported through the electronic adverse event
reporting system.
Goal:
All patients are treated with dignity and respect.
Follow up:
Failure to comply with the policy will result in case
review and re-education of staff and identification of
further improvement actions.
TITLE

REPRESENTATIVE'S SIGNATURE

2

a< ) ATA

(141/(fre,
141
-4-1

44/0

Ith an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing I I eterrnined that
Any deficiency statement ends
icient protection to the patients. (See Instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
Aber safeguards provide
ellowing the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
lays following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
srogram participation.
FORM CMS-2567(02-98) Previous Versions Obsolete

600/ZOOd al 4 /1:ZO 1/40Z 8Z Pr

Event ID1027U11

13967=08

)t2

Facility la 471308

If continuation sheet Page 1 at 8

 DEPARTMENT OF HEALTH AND HUMAN SERVICES
__... _.._ . _.... _ . __.
(X1) PROVIDER/SuPPLIERictiA
ITATEMENT OF DEFICIENCIES
∎ND PLAN OF CORRECTION

IDENTIFICATION NUMBER:

PRINTED: 0 712 8/201 4
FORM APPROVED
•_ . . _ . ____ _ _ _
(X2) MULTIPLE CONSTRUCTION

C
07108/2014

B. WING

471306
NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
pp EtOX 2003

SPRINGFIELD HOSPITAL
(X4) ID
PREFIX
TAG

(X3) DATE SURVEY
COMPLETED

A BUILDING

SPRINGFIELD, VT 06156

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED By FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

G 152 Continued From page 1
to preserving the patients safety and dignity when
restraint or seclusion is used." Procedures listed
in the policy include " maintain dignity and
respect during restraint and seclusion use
through ,..attention to the patient' s needs
...patient comfort related to toileting will be
assessed," Procedures regarding restraint
orders include " The order for physical restraint
for acute behavioral management is limited to:
Four (4) hours for adults "
Patient # 1, whose diagnoses include mania and
delusional thoughts and behavior, was admitted
to the Windham Center! PPS Excluded Distinct
Part Psychiatric Unit of Springfield Hospital on
5/27/14.
Per record review, Physician Progress Notes for
5/27/14 at 5:15 P.M. record the patient is " angry,
agitated, grossly delusional ...threatening to
assault staff„..refuses to discuss voluntary
medication use with MD ... patient was offered
oral medications which s/he refused. ... patient
escorted from courtyard where s/he has been
shouting for several hours down to h/her room
...patient placed in restraint bag "
At 10:08 P.M. the physician documents " patient
seen ,.. patient placed in restraint bag around
dinner time ... patient has not been out of
restraints to use bathroom since 1800 [6:00 P.M]

PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREF X
TAG

C 152

(XS)
COMPLETION
DATE

Restraint Seclusion Policy:
Restraint Seclusion policy and order set will be

09 12 14

revised to remove use of safety coat/ restraint bag.
Policy and procedure will be developed for use of
restraint chair at the Windham Center. Education will
be provided on use of restraint chair along with a
competency sign off for Windham Center staff.

Nursing Notes for 10:05 P.M. record " Dr. Miller
told patient that if s/he took medication we would
allow h/her out of the restraint to go to the
bathroom " . The patient was then offered an
anti-psychotic medication. At 10:15 P.M. Nursing
Notes report Patient #1 " spit out 15 mg tablet. 5
mg tablet was not found. Dr. Miller informed and
s/he told this RN to continue with restraint" .
At 1;15 A.M. on 5/28/14 Nursing Notes state the
1 patient " complained of need to urinate;
'ORM GNAS-2567(02-99) Previous VOrsione Obsolete

800/600d wdZZ'ZO 140/ 8/ Inf

Event ID:027011

BVEZOZZO8 xed

Facility ID:

4

306

If continuation sheet Page 2

of a

 PRINTED: 07/28/2014
FORM APPROVED
OMB NO. 0938-0391
(X3) DATE SURVEY

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
TATEMENT OF OEFICJENCIES
ND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

471306

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

COMPLETED

B. WING

C
07/08/2014

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY. STATE, ZIP CODE

Po BOX 2003

SPRINGFIELD HOSPITAL
(X4) ID
PREFIX
TAG

SPRINGFIELD, VT 05156

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

C 152 Continued From page 2
encouraged to do so in restraint suit" . 4 14 hours
later Nursing Notes record " [Patient #1]
has been on constant 1 on 1 observation for this
shift. S/he has been restrained in the restraint
bag as well. ...has made several requests to go
to the bathroom. Patient was offered PRN [as
needed] meds in order to enable h/her to get up
to use the bathroom, as Dr. Miller specified. " •
AT 5:47 A.M. Patient #1 " reported s/he urinated
in restraint bag. Reassured s/he' d get cleaned
up once out of restraints. "
Per record review at 6:15 A.M. on 5/28/14 a
Physician Order is written " to release patient
'from body restraint bag "
Nursing Notes from 6:20 A.M. document " MD
I called re: patient assessment after having been in
restraints since yesterday evening. Orders given
I to release patient from restraints but to remain
behind locked double doors in the hallway.
Patient agreed to take PRN medications first and
I then s/he could shower. "
A Nursing Note written 34 minutes after the order
to release Patient #1 from the body restraint bag
records the patient was " requesting a cigarette
I and to use phone at 6:30 A.M. checks ...slhe
could have a cig and use the phone if s/he took
medication first. Patient agreed. This RN, along
with 2 MHWs (Mental Health Workers] and
another RN entered patient' s room ...patient was
raised to an upright position and supported while
s/he took 20mg liquid Haldol [an antipsychotic] ...
mouth was checked and clear. Patent then
removed from the restraint and allowed to use the
toilet „,and assisted to the shower. Clean clothes
were provided " ,
Per record review of Social Services notes from
6/4/14 " [Patient #1] spoke about how
traumatizing it had been to be in the restraint bag I
and believes a line had been crossed. States that I
1ORM CMS-2867(02-9e) Previous Versions Obsolete

Event 10:027011

ID
PREF X
TAG

PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSSREFERENCED TO THE APPROPRIATE
DEFICIENCY)

(XS)
COMPLETION
DATE

C 1521

Facility ID:471306

If continuation sheet Page 3 of 8

 PRINTED: 07/28/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA

VVD PLAN OF CORRECTION

IDENTIFICATION NUMBER:

471306

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY

A, BUILDING

COMPLETED

8. WING

C
07/08/2014

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS. CITY, STATE. ZIP CODE

SPRINGFIELD HOSPITAL

PO soX 2003
SPRINGFIELD, VT 05156

(X4)10
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

C 152 Continued From page 3
s/he does not believe it was necessary to be in
the bag as long as s/he was...tearful throughout
exchange in which s/he talked about being in
restraints "
Per interview with the Nursing Director of the
Windham Center Inpatient Psychiatric Unit on
7/8/14 at 1:14 P.M. the Director confirmed Patient
#1 was not treated with respect and dignity
regarding multiple requests to go to the bathroom
and being forced to void then remain in the soiled
restraint bag. The Director also confirmed
coercion was used regarding releasing Patient #1
from the restraint bag only if s/he took a voluntary
medication, and confirmed that the physician ' s
order for restraint was not written for 4 hours and
was not renewed per policy, and that Patient #1
remained in the restraint bag for greater than 12
hours, and Was not released from the restraint
immediately after the order for the restraint to be
discontinued was written.
C 270 485.635 PROVISION OF SERVICES

ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCEO TO THE APPROPRIATE
DEFICIENCY)

(X5)
COMPLETION
DATE

C 152

C 270

Provision of Services

This CONDITION is not met as evidenced by:
Based on patient/patient representative and staff
interviews as well as record review the Condition
of Participation for Provision of Services was not
met as evidenced by:
Per record review, the Windham Center/ PPS
Excluded Distinct Part Psychiatric Unit of
Springfield Hospital staff failed to maintain dignity
and respect during restraint use, used coercion in
order for the patient to accept medications, and
failed to follow procedures regarding orders for
physical restraints per hospital policy.
Refer to tag: 271
:ORM CMS-2567(02-09) Previous Versions Obsolete

Event ID: 021U1l

Facility ID:471305

If continuation sheet Page 4 of 0

 DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
(XI) PROVIDER/SUPPLIER/CUR
TATEMENT OF DEFICIENCIES
ND PLAN OF coRRECTION

IDENTIFICATION NUMBER:

PRINTED: 07/28/2014
FORM APPROVED

OMB NO. 0938.0391

C
0710812014

B. WING

471306

STREET ADDRESS, CITY, STATE, ZIP CODE

NAME OF PROVIDER OR SUPPLIER

PO BOX 2003

SPRINGFIELD HOSPITAL
(X4) ID
PREFIX
TAG

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

SPRINGFIELD, VT 05156

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE AcTi ON SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREF X
TAG

fX6)
COMPLETION
DATE

Right to Respect and Dignity; Right to Refuse

C 271 j 485.635(a)(1) PATIENT CARE POLICIES

C 271

Treatment to the extent permitted by law
All Staff and Physicians will review and sign off on the

The CAH's health care services are furnished in
accordance with appropriate written policies that
are consistent with applicable State law.

Restraint and Seclusion Policy and the Vermont

08 22 14

Department of Mental Health restraint
requirements. A written physician order to continue
restraint will be provided each 4 hours during
duration of restraint use. Patient will be immediately

This STANDARD is not met as evidenced by:
Based on staff interview and record review, the
Critical Access Hospital (CAH) failed to provide
care and services in accordance with established
polices for 1 of 3 applicable patients (Patient #1).
Findings include:
Per record review, the Windham Center/ PPS
Excluded Distinct Part Psychiatric Unit of
Springfield Hospital staff failed to maintain dignity
and respect during restraint use, used coercion in
order for the patient to accept medications, and
failed to follow procedures regarding orders for
physical restraints per hospital policy.
Per record review the policy, titled Restraint and
Seclusion Policy last approved on 4/7/14 states
"...Restraint and seclusion will not be used as a
means of coercion, discipline, convenience or
It is our responsibility to
retaliation by staff
facilitate the discontinuation of restraint or
seclusion as soon as possible...we are committed
to preserving the patient's safety and dignity when
restraint or seclusion is used." Procedures listed
in the policy include " maintain dignity and
respect during restraint and seclusion use
through ...attention to the patient' s needs
...patient comfort related to toileting will be
assessed. " Procedures regarding restraint
orders include " The order for physical restraint
for acute behavioral management is limited to:
Four (4) hours for adults .
Patient # 1, whose diagnoses include mania and
delusional thoughts and behavior, was admitted
to the Windham Center/ PPS Excluded Distinct
RORM CMS-2567(02-99) Previous VorSiOns Obsolete

Event ID: 027U11

removed from restraint once physician provides
order for restraint removal. Coercion will not be
utilized to facilitate restraint removal.
Education:
Staff will be educated to methods of potential
coercion with attention to use of medications,

09 05 14

smoking, and toileting as potential methods of
coercion. Therapeutic alternatives based upon
patient assessment will be considered prior to
implementation of any restrictive restraint. These
include comfort measures, activity diversion
measures and psychosocia I measures.
Monitoring:
Behavior flow sheets will be reviewed to assess
documentation of appropriate assessments,
implementation of appropriate interventions and
treatment outcomes. Any deviation from policy will
be reported through the electronic adverse event
reporting system.
Goal:
All patients are treated with dignity and respect.
Follow up:
Failure to comply with the policy will result in case
review and re-education of staff and identification of
further improvement actions.
Restraint Seclusion Policy:
Restraint Seclusion policy and order set will be
revised to remove use of safety coat/ restraint bag.

09 12 14

Policy and procedure will be developed for use of
restraint chair at the Windham Center. Education
will be provided on use of restraint chair along with a
competency sign off for Windham Center staff.

Facility ID: 471306

If continuation sheet Page 5 of 8

 PRINTED: 07/28/2014
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
iTATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO, 0938-0391
(X2) MULTIPLE CONSTRUCTION

C
0710812014

B.WING

471306

STREET ADDRESS. CITY, STATE. ZIP CODE

NAME OF PROVIDER OR SUPPLIER

PO BOX 2003

SPRINGFIELD HOSPITAL
(X4) ID
PREFIX
TAG

(X3) DATE SURVEY
COMPLETED

A. BUILDING

SPRINGFIELD, VT 05156

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

C 271 Continued From page 5
Part Psychiatric Unit of Springfield Hospital on
5/27/14.
Per record review, Physician Progress Notes for
5/27/14 at 5:15 P.M. record the patient is " angry,
agitated, grossly delusional ...threatening to
I assault staff. ...refuses to discuss voluntary
I medication use with MD ... patient was offered
oral medications which s/he refused.
patient
escorted from courtyard where s/he has been
shouting for several hours down to h/her room
...patient placed in restraint bag "
At 10:08 P.M. the physician documents " patient
seen ... patient placed In restraint bag around
dinner time .,. patient has not been out of
restraints to use bathroom since 1800 [6:00 P.M.]

ID

PREF X
TAG

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(X)
COMPLETION

DATE

C 271

Nursing Notes for 10:05 P.M. record " Dr. Miller
told patient that if s/he took medication we would
allow h/her out of the restraint to go to the
bathroom " . The patient was then offered an
anti-psychotic medication. At 10:15 P.M. Nursing
Notes report Patient #1 " spit out 15 mg tablet. 5
mg tablet was not found. Dr. Miller informed and
s/he told this RN to continue with restraint" .
At 1:15 A,M. on 5/28/14 Nursing Notes state the
patient " complained of need to urinate;
encouraged to do so in restraint suit" 4 1/2 hours
later Nursing Notes record " [Patient #1]
has been on constant 1 on 1 observation for this
shift. S/he has been restrained in the restraint
bag as well. ...has made several requests to go
to the bathroom. Patient was offered PRN [as
needed] meds in order to enable h/her to get up
to use the bathroom, as Dr. Miller specified. "
AT 5:47 A.M. Patient #1 " reported s/he urinated
in restraint bag. Reassured s/he ' d get cleaned
up once out of restraints. "
Per record review at 6:15 A.M. on 5/28/14 a
Physician Order is written " to release patient
:ORM CMS-2547(02-09) Prftioua Versions Obwkete

Event ID: 027U11

Fadtity ID: 471306

If continuation sheet Page 6 of 8

Jag-

 PRINTED: 07/28/2014
FORM APPROVED
OMB NO. 0938-0391
(X3) DATE SURVEY

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
kNO PLAN OF CORRECTION

(Xi)

PROVIDEFUSUPPLIER/CLIA
IDENTIFICATION NUMBER:

471306

(X2) MULTIPLE CONSTRUCTION
A,

COMPLETED

BUILDING

C
07(0812014

IT WINO

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE. ZIP CODE

SPRINGFIELD HOSPITAL

PO BOX 2003
SPRINGFIELD, VT 05156

(X4) ID
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY oR L5O IDENTIFYING INFORMATION)

C 271 Continued From page 6
from body restraint bag " .
Nursing Notes from 6:20 A.M. document " MD
called re: patient assessment after having been in
restraints since yesterday evening. Orders given
to release patient from restraints but to remain
behind locked double doors in the hallway.
Patient agreed to take PRN medications first and
then s/he could shower, "
A Nursing Note written 34 minutes after the order
to release Patient #1 from the body restraint bag
records the patient was " requesting a cigarette
and to use phone at 6:30 A.M. checks ...s/he
could have a cig and use the phone if s/he took
medication first. Patient agreed. This RN, along
with 2 MHWs [Mental Health Workers] and
another RN entered patient ' s room ...patient was
raised to an upright position and supported while
s/he took 20mg liquid Haldol tan antipsychotic]
mouth was checked and clear. Patient then
removed from the restraint and allowed to use the
toilet ...and assisted to the shower. Clean clothes
were provided " ,
Per record review of Social Services notes from
614114 " [Patient #1] spoke about how
traumatizing it had been to be in the restraint bag
and believes a line had been crossed. States that
s/he does not believe it was necessary to be in
the bag as long as s/he was„.tearful throughout
exchange in which s/he talked about being in
restraints "
Per interview With the Nursing Director of the
Windham Center Inpatient Psychiatric Unit on
7/8/14 at 1:14 P.M. the Director confirmed Patient
#1 was not treated with respect and dignity
regarding multiple requests to go to the bathroom
and being forced to void then remain in.the soiled
restraint bag. The Director also confirmed
coercion was used regarding releasing Patient #1
from the restraint bag only if s/he took a voluntary
:ORM CMS-2557(02-99) Previous Versions Obsolete

Event ID: 027U11

ID
PREF X
TAG

PROVIDER'S PLAN OF CORRECTION •
(EACH CORREcTIVEACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(X5)
COMPLETION
DATE

C 271

Facility

471306

If continuation

sheet Page 7 of B

c_,7x 102--

 PRINTED: 07/28/2014
FORM APPROVED
OMB NO, 0938-0391
(X3) DATE SURVEY

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
iTATEMENT OF DEFICIENCIES
N ND PLAN OF CORRECTION

(X*1) PROVIDER/SUPPLIERCLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

COMPLETED

B. WING

07/06/2014

C
471306
NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

SPRINGFIELD HOSPITAL

PO BOX 2003
SPRINGFIELD, VT 05156

(X4)11)
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR L$C IDENTIFYING INFORMATION)

ID
PREF X
TAG

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVEACTION SHOULD BE
CROSS-REFERENCED TO THE AP PROPRV1TE
DEFICIENCY)

(X5)

COMPLETION
DATE

A
C 271 Continued From page 7
medication, and confirmed that the physician' s
order for restraint was not written for 4 hours and
was not renewed per policy, and that Patient #1
remained in the restraint bag for greater than 12
hours, and was not released from the restraint
immediately after the order for the restraint to be
discontinued was written.

'ORM GMS-2567(02.80) Previous Versions Obsolete

Event ID:027011

C 271

parnini ID: 471306

If continuation sheet Page B of B