Still from surveillance footage of the restraint of Keith Carter, traced over to protect individuals identities. Courtesy of DRDC identities. Courtesy of DRDC Credit: Courtesy Disability Rights DC / University Legal Services

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In January, more than a dozen staff members at St. Elizabeths Hospital—the District’s only public psychiatric hospital—carried out a premeditated ambush of an apparently calm patient. They surrounded him as he was standing calmly in a common space, and dragged him to another room where they tied his arms and legs down to a bed, pulled down his pants, and injected him with psychotropic medication. They then left him tied to that bed for hours, according to a new report by a prominent D.C. disability rights group. 

Then in April, hospital staff kept another patient—who had untreated, undiagnosed fractures in his hip and arm—tied by all four limbs to a bed for almost two hours. Staff were the ones who broke his bones, and it was almost 24 hours before the man received treatment for his injuries. 

And over the course of April and May, counter to hospital policy, staff used extreme measures to restrict the movement of a third patient, who is a survivor of sexual abuse, seven times. Sometimes, staff pulled her pants down in front of male staff members to inject medicine into her buttocks; they repeatedly tied her to a bed or locked her up alone in a room, leaving her there for up to four hours.

These incidents are detailed in the report that the Disability Rights DC (DRDC) program at University Legal Services—an organization that monitors treatment quality at various hospitals in D.C. and advocates for disability rights—sent to the hospital and to the Department of Behavioral Health (DBH) (which operates St. Elizabeths) on Wednesday. The report describes multiple instances where DRDC claims St. Elizabeths illegally used restraint. Restraint is a controversial practice where staff control a patient by restricting their freedom of movement, generally by either physically holding them down or tying their arms and legs to a bed, and in the report, DRDC severely criticizes the hospital for using the technique far too liberally. The result, according to DRDC, has been “serious staff violations” of federal and local law and “disturbing staff abuses” toward patients.

Restraints were once a rare occurrence at St. Elizabeths. In the past several years, though, the hospital’s use of the technique has increased astronomically. According to the hospital’s public performance reports, in 2013, they placed patients in restraints only four times all year. In 2018, the annual count was 782. (The average daily patient population didn’t change much between those years; it was 261 in 2013 and 270 in 2018.)

“That’s unacceptable. It’s just unacceptable. That’s more than twice a day,” says Debbie Plotnick, vice president of the mental health advocacy group Mental Health America. “Restraint should be a last resort… There’s clearly something wrong with that picture.”

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Credit: Darrow Montgomery/File

Twenty-four hours before the ambulances arrived, John Holmes barricaded himself in his room at St. Elizabeths. According to attorneys at DRDC, when Holmes arrived at the hospital, staff determined he had symptoms of disorganized schizophrenia. (John Holmes is not his real name; all the patient names in the report are pseudonyms.) Hospital records, reviewed by DRDC, indicate that on the night of April 19, he had walked into the bedroom of another patient and then walked into a bathroom, and when staff told him to leave the bathroom, he threatened to “mess a staff up.” They called for back-up, at which point Holmes went back into his room, using his body to block the door. He later told DRDC that he was “paranoid,” feeling that other patients and staff were going to hurt him, and so he didn’t want anyone to come inside. Staff reported that he threatened them with a milk carton, claiming that it was full of urine and that he would throw it at them.

Then, with the aid of a plastic shield, they broke down the door. Holmes says this knocked him to the ground, and that staff then fell on top of him, breaking his arm and his hip. Staff grabbed him by “his extremities,” according to hospital records, and then carried him to another room. There, they strapped his arms and legs to a bed, and kept him that way for an hour-and-a-half. Eventually, they freed his arms to take his vitals—he sat up, and vomited. They got him cleaned up and put him in a wheelchair, sending him to bed without assessing his injured limbs. Holmes later told DRDC that that night, he thought he was going to die.

The next evening, over 16 hours after he’d been tied down, hospital records state that Holmes was finally evaluated by a nurse practitioner, who ordered an X-ray. Still, hours went by, until a doctor noticed that his left leg was swollen and that his X-ray showed an acute hip fracture. They called 911, and Holmes arrived at George Washington University Hospital almost 24 hours after staff broke his door down. Upon arrival, DRDC says, GW staff noted that he was in “severe” pain, and that his leg was “externally rotated, shortened and swollen.” They also noticed, for the first time, that his arm was broken, and put it in a cast. That night, Holmes underwent surgery, as doctors inserted permanent metal hardware into his hip.

In addition to the potential for physical injury, it’s widely documented that putting someone in restraints can cause serious, lasting psychiatric harm, especially for people who already have serious mental illnesses. And because of that potential for harm, both District and federal law seriously restrict when and how restraints can be used. St. Elizabeths’ own policy on restraint concisely outlines the law’s chief requirements. First, “restraint shall only be used in emergency situations that pose an immediate risk of an individual physically him/herself, staff, or others.” Second, it should only be used in the absence of alternatives, “when less restrictive options have been viable or have been ineffective.”

But Andrea Procaccino, a staff attorney at DRDC, says that that policy—and the law—are not always being followed. Since 2013, the number of times St. Elizabeths used restraints annually increased by almost 20,000 percent, and Procaccino says, “We just don’t see evidence of them trying other things.” She admits that Holmes’s situation was particularly difficult, but says that perhaps staff could have avoided the violent encounter by waiting for Holmes to calm down, or by asking him what he needed, as professionals trained in de-escalation. “That’s in their manual,” she tells City Paper. “I wasn’t there. But I’d expect the reports to say these are the three things we tried to do [before breaking down the door and tying Holmes to a bed], and they didn’t work. Which is what the law requires them to do.”

“[Restraint] should be unusual,” says Procaccino. “If it happens, everyone should sit back, take the time to try to figure out how it can not happen again. But I think they do it so often that it just becomes rote.”

“Saint Elizabeths Hospital is committed to the highest standards of recovery-focused patient care,” St. Elizabeths CEO Mark Chastang tells City Paper. “We are reviewing recommendations in the report and will continue our work with University Legal Services to make sure every patient gets the best and most appropriate treatment to recover and rejoin family and friends in the community.”

DRDC obtained video evidence of another incident they say suggests the hospital is using restraints in situations that are nowhere near emergencies. Around 11:15 a.m. on Jan. 19, before he was dragged into a room to have his arms and legs tied to a bed, surveillance footage showsKeith Carter (also a pseudonym the report uses) calmly standing in a common room. Patients and staff are lounging around, and Carter talks briefly to a staff member. Hospital records reviewed by DRDC state that at some point during the day, Carter had been “sexually inappropriate and verbally threaten[ed] two female staff.” It is unclear when that took place.

About 15 minutes go by. Carter appears calm, standing near the nurses’ station. Someone’s napping on the couch, and staff wait nearby. Then four security guards walk in, and one of them puts on gloves. Carter walks up to some of the staff that are gathering around him, and says something. One of them waves him away, taking a sip from their drink.

More staff and guards arrive, one holding a large plastic shield. All the other patients have left the room by now—it’s just the staffers and Carter. They gather around the room, methodically, no one approaching the patient, as two security guards take another patient out of the room to which Carter is about to be dragged. By now, everyone is wearing blue gloves.

And then they close in. Thirteen staff members surround Carter. Several grab onto his arms, another pushes him from behind, and they drag him into the other room. According to DRDC’s review of hospital records, they then tied his arms and legs down to the bed, and pulled down his pants, injecting psychotropic medication into his buttocks. Staff then kept him tied to that bed for almost two hours.

“Mr. Carter perceived it as a punishment [for his ‘inappropriate’ remarks],” says Procaccino. “I don’t know if it was. But the law says restraint can’t be used as a punishment.”

“That [incident] is really disturbing,” she says, “because that seems like a real culture. Like that’s just what they do.”

St. Elizabeths has a long history of misusing restraints, but in the past, when pressed, the hospital has successfully implemented reforms. In 2005, the U.S. Department of Justice investigated the conditions at St. Elizabeths and filed a lawsuit against the city for violating patients’ constitutional rights. One of the chief issues in the lawsuit was the hospital’s use of restraint and seclusion. (Seclusion refers to when a patient is kept locked alone in a room, like solitary confinement.) Federal investigators found that staff were often using the practices inappropriately and excessively, in ways that were “clinically inexplicable” and “substantially depart from generally accepted professional standards.” In one instance, investigators said, a patient attempted suicide; in response, staff members just tied her arms and legs to her bed for 24 hours. Four days later, she attempted suicide again.

As part of the eventual settlement, DOJ required that St. Elizabeths reform the way it used seclusion and restraint, including training all its staff on “less restrictive interventions.” It took almost a decade of hard work for the city to successfully implement all the reforms that DOJ asked for. In 2014, the feds decided that St. Elizabeths had come into compliance with federal law and dismissed the lawsuit—with the stipulation that the city continue to let University Legal Services monitor conditions at the hospital.

But since the Department of Justice stepped back, the frequency at which St. Elizabeths puts patients in restraints has increased astronomically. Since 2013, when on average, 0.08 percent of patients were put in restraints any given month, the monthly percentage of patients put in restraints has gone up every single year. And that monthly average peaked last December—over the course of the month, more than 20 percent of the hospital’s patients were forced into restraints at some point in time. 

Neither Chastang nor DBH addressed City Paper’s request for comments on this increase.

The rate at which the hospital uses seclusion has also gone up every year since 2013. In June, City Paperreported that the hospital had—very recently—kept several patients locked alone in seclusion for weeks on end, which advocates said was illegal and dangerous; the hospital responded that it would change its policy around extended seclusion after DC Health decided this practice violated federal regulations.

Plotnick emphasizes that given the potential for serious psychiatric harm, restraint should never be used lightly. “It’s extraordinarily traumatizing,” she explains, emphasizing that many patients at hospitals like St. Elizabeths already have a long history of trauma. “Imagine what it is that happens when a person who has been a victim of sexual violence has big, burly men come and tie them up.”

St. Elizabeths’ policy on restraint and seclusion states that seclusion is “contraindicated” for “individuals who have a trauma history,” and D.C. regulations also require that doctors take special consideration of a patient’s trauma history when ordering seclusion or restraint. 

DRDC says that these policies are not always heeded. DRDC attorneys interviewed and reviewed the records of one longtime St. Elizabeths patient, who, according to a hospital social worker, “reported a history of sexual, physical and emotional abuse beginning at a young age.” But despite this history, hospital staff placed her in seclusion or restraint seven times in April and May alone. This was in response to altercations she was having with another patient. Sometimes, they just separated the two of them; other times, instead, the patient was tied to a bed or locked alone in a room. Once, she was kept that way for four hours.

D.C. law mandates that after a hospital uses seclusion or restraint, staff determine if something could be done to prevent a similar incident from happening again. When staff asked the patient what could help stop future altercations, she responded, “I need to go to another unit.” “Inexplicably,” DRDC says in its report, “[hospital records] did not indicate what, if any, measures staff implemented in response.”

Additionally, over the course of those two months, the patient was injected with psychotropic medication against her will five times. Sometimes, her pants were pulled down in front of male staff members, reports DRDC, so that the medication could be injected into her buttocks.

According to its own data, the number of times St. Elizabeths used involuntary medication went from 485 in 2013 to 768 in 2018. District law also seriously restricts the use of drugs as restraints, but DRDC says that in 2010, the hospital redefined what it classifies as a drug-based restraint. The new definition, the attorneys claim, “effectively allows the hospital to assert that its staff no longer administers drugs as a restraint, even though staff actions frequently meet the statutory definition of drugs as a restraint, denying the patients the protections D.C. law affords them.”

Procaccino thinks that if the hospital is going to change the way it uses restraint, it won’t be as simple as altering a few policies. “I think it’s a culture. I think it does come from the top,” she says. She points to other states, like Pennsylvania, where health care leaders have made it a priority to use seclusion and restraint less frequently, and have managed to virtually eliminate the practice in their public hospitals: “I think if you don’t have that from the top, it’s going to be difficult to change anything.”

In the report DRDC sent to DBH and the hospital, they recommended that DBH hire an independent consultant to figure out why the hospital uses restraint and seclusion so frequently, and to implement any necessary reforms. “We think it’s critical that they bring someone else in,” explains Procaccino, “because whatever they’re doing—whatever they’re trying—it’s not working.”

Plotnick emphasizes that excessive use of seclusion and restraint can make hospitals more dangerous for patients and staff alike. “I understand that people can be very difficult—I’m not downplaying that. There can be serious issues,” she says. “But what often contributes to those serious issues is trauma, and trauma that occurred in institutional settings. You get into a negative feedback loop. The situation gets worse and worse. And people get hurt.”

But above all, Plotnick says, it’s a matter of making sure that when psychiatric patients go into a hospital, they receive therapy there, not punishment. “Having a mental illness is not a crime,” she tells City Paper, slowly and emphatically. “But treating someone with mental illness like a criminal is, in fact, a crime.”