Within the limitations of court-imposed confinement, federal law requires that hospital administration actively pursue the timely discharge of patients to the most integrated, appropriate setting that is consistent with patients’ needs. Olmstead v.
L.C., 527 U.S. 581 (1991).20 From the time of admission, the
20 In February 1974, a class of individuals civilly committed to St. Es filed a lawsuit against the federal
government (which operated St. Es at the time) and the District of Columbia (which was responsible for community mental health
factors that likely will foster viable discharge for a particular patient should be identified expressly, through professional
assessments, and should drive treatment interventions. Without clear and purposeful identification of these factors or issues to be addressed, the individual is denied rehabilitation and other services and supports to assist the patient in acquiring,
developing or enhancing the skills necessary to function in a community setting.
Preparation for discharge while in the hospital appears to be almost nonexistent. In no instance could we determine that a treatment team actually had prepared a patient to transition to, or succeed in, a new setting. In fact, the provision of
transition supports were almost never discussed in the numerous patient records that we reviewed. Rehabilitation goals and functional recovery were rarely identified. Expressed and
demonstrated skills in work, school, or independent living were rarely analyzed. Finally, the patient played virtually no
significant role in the discharge process.
Although there are no designated “discharge units” at St. Es, Units CT2C and CT2D appear to serve as discharge units because they are units with fewer restrictions and structured for patients who are higher functioning. However, unlike typical discharge units, St. Es patients appear to remain on these units for extended stays. Patients on Units CT2C and CT2D have
treatment plans that include interventions with little, if any, likelihood of success, thereby preventing discharge and community reintegration. For example, R.F. is reportedly selectively mute and refuses medication and blood work, but there are no plans to modify these behavioral problems. Similarly, Q.P.’s goals are to avoid the influence of hallucinations and delusions. Although centers in the District). Dixon v. Williams, No. 74-285 (D.D.C.
filed Feb. 14, 1974). The class action, which was filed under a D.C. statute, alleged that the defendants had failed to fulfill their duty to return patients at St. Es to the community as soon as possible and insofar as possible. The class sought community-based mental health treatment alternatives under the least
restrictive conditions necessary. We are fully aware of the existence of the Dixon litigation and the ongoing efforts to address community integration of St. Es patients in the context of that case. Nevertheless, federal law also requires us to address the issue of placement in the most integrated,
appropriate setting. Moreover, our review discusses the actual barriers and deficiencies of St. Es’ procedures, services, and treatment for ensuring that individuals can be successfully discharged into the community.
these types of problems might be successfully addressed and reduced through a systematic course of cognitive behavioral therapy, no such plan was present.
To the extent that St. Es has discharge plans, they are overly general, non-specific, unattainable and/or irrelevant to discharge. For example, it is common for discharge goals to state “increase awareness of illness” and “reduce psychotic symptoms.” These goals are not necessarily prerequisites to successful functioning and living in the community. More relevant treatment targets for community functioning, such as improving poor daily living skills, reducing aggressive acting out, and eliminating incontinence are routinely ignored in discharge planning.
It is also important to note that when patients are discharged from St. Es, they are ill-equipped to succeed in community placement. St. Es does not appear to provide any
programs to prepare patients to return to the community, such as regular visits to community residences or training in skills such as shopping, laundry, and self-medication. In fact, there
appears to be little attention paid to the successful transition of patients to community placements. This is illustrated by a particularly disturbing example involving patient B.E. During our visit, B.E. was scheduled to be discharged at the end of the week. While at St. Es, and, for at least six months prior to our visit, he wore a helmet, ostensibly to protect himself from self-injurious behavior; he was on one-to-one observation for the
majority of the time; his bed was wheeled into the day room at night to be observed by night staff; and his bed was fitted with wrist restraints and a urinal. Thus, it is hard to understand how this patient was to be safely discharged to a less intensive outpatient environment, when he was hospitalized under such
extreme and continuous restrictions.
St. Es’ failure to provide adequate, individualized
discharge planning significantly deviates from generally accepted professional standards and contributes to unnecessarily prolonged hospitalization and to inappropriate, unsuccessful placements in the community. As a consequence, patients are harmed or exposed to the risk of harm by the effects of prolonged
institutionalization and by being denied a reasonable opportunity to live successfully in the most integrated, appropriate setting.
III. MINIMUM REMEDIAL MEASURES
To remedy the deficiencies discussed and to protect the constitutional and federal statutory rights of the patients at St. Elizabeths Hospital, the District of Columbia should promptly implement the minimum remedial measures set forth below:
A. PROTECTION FROM HARM