Lawyers from a watchdog agency and the state Mental Hygiene Legal Service say they've found that patients on the psychiatric units at Bellevue hospital in Manhattan are physically restrained and forcibly injected with sedatives at dramatically higher rates than patients at other public hospitals in the city. They also found that the hospital allegedly under-reports these incidents, in apparent violation of state policy directives and federal law.
Disability Rights New York, a federally mandated watchdog, released a report earlier this month showing the rates of restraint use and forced intramuscular sedative injections at Bellevue.
Restraints fall broadly into two categories: physical or chemical. Physical restraints include manual restraints, such as holding a patient still, or mechanical restraints, such as using straps to tie a patient to a bed. Chemical restraints are typically involuntary intramuscular injections of a powerful drug cocktail—most commonly the antipsychotic Haldol and the sedative Ativan—that calms patients down or puts them to sleep. Bellevue's restraint policy prohibits the use of chemical restraints, but data and documents show that the hospital is still using them.
The report found that between September 2014 and August 2015, Bellevue staff physically restrained psychiatric patients 2,417 times, a rate of 6.7 restraint incidents per bed. Kings County Hospital in East Flatbush, Brooklyn, had the next highest rate of restraint incidents among public hospitals—4.6 per bed.
Rates of restraint usage vary widely across Bellevue. One small unit for adolescents on the west side of the hospital's 21st floor documented 6.9 restraint incidents per bed for the year, while an identical unit on the floor's north side restrained only 1.8 per bed. These units are the same size and serve the same population. The report notes that, based on these numbers, "a teenager who happens to be hospitalized on the west side of the floor rather than on the north side has a nearly five times greater chance of being placed in mechanical restraints during his or her hospitalization."
Several extreme cases stand out in the report. A child with autism was allegedly restrained during 36 of the 43 days she was at Bellevue. Another patient was allegedly left in restraints for 20 hours over two days.
The use of restraints can have serious psychological effects on patients. A 2002 study cited in the report found that patients often feel "isolated and ashamed" after being restrained. Bellevue's own policy on restraints says that they have "the potential to produce serious consequences, such as physical and psychological harm, loss of dignity, violation of an individual's rights, feelings of isolation and even death."
New York State's Office of Mental Health has long advocated for reducing the use of restraints. In a statement on the agency's website, Commissioner Ann Marie Sullivan writes that the use of restraints "can almost always be prevented," and notes they are "non-therapeutic, and carry the risk of serious injury."
Valentina Morales, attorney-in-charge at the Mental Hygiene Legal Service's Bellevue office and one of the primary researchers on the report, says restraints can be traumatic for patients, especially people who have been victims of sexual or physical abuse. "We're very concerned that Bellevue, which has a national and international reputation for being the gold standard of psychiatric care, is using these interventions at this rate," says Morales. "Our research revealed cases where individual patients were placed in restraints so frequently during their hospitalization that restraint almost appeared to be an element of their treatment plan."
The report's authors also claim the hospital has inadequately documented its use of restraints, in violation of state and federal regulations.
Bellevue provided Mental Hygiene Legal Service with copies of all of the hospital's restraint reports from September 2014 to August 2015; Health + Hospitals provided its own data on the total number of restraint incidents during that period. The organization found significant discrepancies between the numbers reported—Health + Hospitals listed almost twice as many restraint incidents at Bellevue as were reported by the hospital.
Federal and state regulations require reporting of all restraint incidents. If the data from Health + Hospitals are accurate, Bellevue seems to be violating those regulations. The report calls the hospital's reporting "disturbingly erratic, at best."
Further, Bellevue has not been reporting forced intramuscular injections as restraints, even though the shots meet state and federal definitions of chemical restraints. Bellevue's restraint incident numbers would increase drastically if these injections were included. Data from Health + Hospitals that was appended to the report shows that Bellevue allegedly used forced injections 13,216 times between September 2014 and August 2015.
"To the extent that the use of restraints is not appropriately documented, that's a violation," says Mark Murphy, a Disability Rights New York attorney who helped spearhead the report. "If you don't have accurate numbers, the problem may be much worse than you think it is."
Doctors at Bellevue have argued that the hospital's patients are sicker and more violent than patients at other facilities in the city, and that elevated rates of restraint and forced medication use simply reflect that reality. The hospital claims that rules requiring public hospitals to accept all patients regardless of ability to pay, coupled with Bellevue's size and name recognition, make the hospital a major landing point for the city's most seriously mentally ill.
But lawyers from Disability Rights and the Mental Hygiene Legal Service express skepticism about this claim. "MHLS operates in other public hospitals as well, so we know that many of these patients are seen in other hospitals," says Morales. "And if Bellevue believes that its patients are more difficult to treat, that's just one more reason why it should focus on figuring out how to safely and therapeutically address their treatment needs," she says.
Murphy agrees. "I don't think it's the case that other hospitals don't get acute patients or don't get patients who act out," he says. "I don't think there's any data to support that."
While there isn't data available that could definitively prove or disprove Bellevue's claim that it serves a higher-need patient population, a report released last year by City Limits shows that Bellevue's readmission rate—a key indicator of the severity of patients' conditions—was only marginally higher than the average for the city's public hospitals.
Bellevue's Office of Public Affairs declined to comment on the report.
Ben Hattem is a Brooklyn-based journalist and the 2016 recipient of the Nellie Bly Cub Reporter award from the New York Press Club.