On Wednesday, Disability Rights Connecticut (DRCT) released the findings of its three-year investigation into the Connecticut Mental Health Center (CMHC) alleging unsafe conditions, improper treatment, frequent and unchecked sexual abuse, lack of oversight and violations of patients’ rights. In its corresponding report, the DRCT called for “urgent and immediate corrective action to prevent further irreparable harm.”
“CMHC is failing to help its patients become more independent, productive members of society. On average, patients remain at CMHC for a year or more,” explained Rachel Mirsky, Supervisory Attorney at DRCT, who led the investigation. “Administrative neglect has led to inadequate treatment of patients including safety from harm, excessive use of restraint and seclusion, and inadequate treatment plans to improve patient wellbeing and provide skills necessary to transition out of an institutionalized setting.”
According to its website, DRCT is a “statewide non-profit organization with a mission to advocate for the human, civil, and legal rights of people with disabilities in Connecticut.” CMHC is a 20-bed, inpatient facility located in New Haven, designed to treat patients with mental illness, and is run by the state’s Department of Mental Health and Addiction Services (DMHAS) in cooperation with the Yale University School of Medicine, Department of Psychiatry.
The DRCT initiated its investigation, which was conducted from April 2021 to February 2024, after receiving multiple patient complaints regarding CMHC’s level of care. The investigation paints a picture of CMHC as a place where sexual abuse runs rampant and unreported, and abusers go unchecked, where staff frequently jump to last-resort measures first to deal with challenging patients, and where a combination of poor care and poor release planning leads to many patients being quickly readmitted upon their release.
The facility itself also was found to be physically unsafe; it suffers from persistent rat infestations, contains ample asbestos flooring, and has faulty sprinklers. Involuntarily admitted patients, who typically suffer from severe mental illness and behavioral issues, were also frequently housed with voluntary research patients, putting the voluntary patients at unnecessary risk.
Perhaps the most concerning allegations raised by the investigation were the reported lack of proper documentation, investigation, or prevention of sexual abuse incidents. DRTC wrote that CMHC staff failed to report that a female patient was sexually abused on three separate occasions by three different male patients and took no steps to correct the abusers’ behavior. Another patient was found to be responsible for over 50 sexually abusive incidents in seven months, none of which the CMHC staff investigated. Staff also failed to take any measures to prevent this patient from continuing their pattern of abuse.
Four of the five patient allegations of sexual abuse reviewed by DRCT went uninvestigated by CMHC staff. Two of them alleged unwanted sexual contact by staff, one of them alleged a staff member asking for a patient to perform oral sex, and another allegation centered on abuse the patient had suffered at the hands of a family member prior to the patient’s admission.
The patient who suffered abuse at home highlighted another significant problem of CMHC’s care; its failure to draft intuitive discharge plans that prevent patients from requiring readmission.
“CMHC released one patient back to her family home, the same home where a family member sexually abused the patient and where the alleged aggressor continued to reside, although the patients’ records stated that CMHC knew the circumstances of the sexual abuse incident,” read the investigation’s summary. “Following this discharge, the patient was readmitted to CMHC within 13 days.”
The DRCT also found several instances in which CMHC staff were quick to use physical restraints or inject patients with tranquilizers in situations where they were not permitted to do so. One patient was restrained 14 times and isolated from other patients six times over the course of their 32-week stay.
Per the CMHC’s own policies, using restraints, tranquilizers and involuntary isolation are considered last-resort measures for patients who pose an imminent threat to themselves or others, and should not be used as punishment. Use of these methods requires thorough documentation and close supervision, and patients who are restrained, tranquilized, or isolated are supposed to receive modified behavior plans. The DRCT found numerous instances of staff failing to follow proper procedure regarding the use of these measures’ authorization, documentation, supervision or follow-up care.
“DRCT’s investigation showed that CMHC did not adequately integrate behavioral interventions through positive behavioral support plans, but, rather, relied heavily upon restraint and seclusion in response to patient aggressive behavior,” read the report.
While the investigation found staff quick to use its most extreme measures, it also found staff were inadequate at providing therapeutic care. Staff did not follow patients’ individual treatment plans, or review or change failing treatment plans. Staff also failed to hold patients accountable for missing prescribed group therapy sessions or successfully encourage patients to attend them. The investigation also found staff had “a lack of respect and dignity towards patients,” and promoted reliance on staff instead of promoting patients’ independence.
Ultimately, the DRCT attributed the numerous problems with CMHC as a result of inadequate and unclear policies, a failure to follow those policies, and a lack of risk management and quality assurance. The investigation said staffers do not collect data or evaluate the behaviors and situations that put patients at risk, nor does it implement corrective actions to prevent patients from experiencing future instances of abuse, aggression, or punishment.
“Currently without a risk management system in place to review, correct… and monitor these behaviors, CMHC is failing to adequately ensure the safety of its patients,” read the investigation summary.
Ultimately, the DRCT has recommended that CMHC be placed under the oversight of the state’s Department of Health, and that CMHC staff provide an annual report to DRCT that outlines the ways in which it’s correcting its various shortcomings.
“CMHC’s patients are the sons, daughters, mothers, and fathers of families that love and care about them. They deserve more from CMHC,” Mirsky added. “What CMHC is currently doing is not enough.”
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