Scathing report slams Bridgewater State Hospital for 'abuse' and 'deplorable' conditions

BRIDGEWATER — The Disability Law Center, a non-profit organization responsible for the rights of Massachusetts residents with disabilities, published a scathing report Wednesday detailing a series of violations at Bridgewater State Hospital — including significant mold contamination, unlawful restraint practices and inadequate access to medical treatment.

Bridgewater State Hospital (BSH) is a medium security men’s prison owned by the Massachusetts Department of Correction (DOC) that houses people with serious psychiatric needs that have pending criminal charges or who have been found not guilty by reason of insanity, according to the Massachusetts Association for Mental Health.

The Disability Law Center’s most recent investigation into Bridgewater State was conducted from June to December of 2023 and included weekly onsite visits, meetings with patients, staff and administrators, viewing records reports and surveillance, and corresponding with the DOC and Wellpath, its contracted health provider at Bridgewater State.

"DLC’s monitoring efforts reveal persistent legal violations, abuse, inadequate medical and mental health treatment, and mold contamination at BSH," Disability Law Center (DLC) Director of Litigation Tatum A. Pritchard wrote in a statement. “Failure to prioritize appropriate, stabilizing care and protect individuals with mental health disabilities at BSH from compounding trauma has real consequences for those individuals, their loved ones, and the Commonwealth’s larger mental health and criminal justice systems.”

The issues revealed in the 87-page report are only the most recent in a decades long string of allegations of abuse and mismanagement at Bridgewater State Hospital.

Here's an inside look at what's going on at Bridgewater State Hospital, according to the DLC.

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Illegal medication restraints

Since Wellpath contracted with the DOC to provide services at Bridgewater State, the use of seclusion and 4-point restraints at the facility have gone down "significantly," but the use of forced medication persists, according to the report.

From June 16 to Dec. 15 of 2023, involuntary medication was used to restrain patients 231 times on 118 individuals, according to the report.

Bridgewater State's current medication restraint policy allows for its use under an emergency treatment order (ETO) when a patient presents with behaviors that pose only a "potential" harm to self or others.

According to the report, the DOC’s policy regarding forced medication violates the Massachusetts law that states the restraint of a person with a mental illness may only be used in cases of emergency. This includes the occurrence of or serious threat of extreme violence, personal injury or attempted suicide, according to Mass.gov.

“Through our monitoring, including review of daily reports, restraint and seclusion order forms, and other records, interviews, first-hand observations, and watching video footage, DLC confirmed systemic legal violations in the application of ETOs again during the last reporting period,” they wrote.

In response to the reports’s findings, the DOC drafted new policy language for the use of seclusion, restraint and involuntary psychotropic medication in January, according to the report. The Disability Law Center and DOC will meet this month to discuss the updated draft policy language, they said.

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‘Deplorable' conditions: Asbestos and mold largely ignored

As part of their investigation, the Disability Law Center hired Gordon Mycology, a mold and air quality inspection specialist with 27 years of experience, to check the facility for environmental contamination.

According to Gordon Mycology’s mold inspection report, which was included in the Disability Law Center's report, mold growth and asbestos previously identified in the past three years of inspections were still present, creating un-safe conditions for patients and staff.

“HVAC systems observed during the inspection continued to be in deplorable condition, some with air handlers in wet and flooded basements with rampant mold growth and asbestos. The black dust/debris inside HVAC system air handlers and supply diffusers remained, seemingly untouched, along with unacceptable levels of mold growth,” Gordon Mycology wrote in its report.

“Overall, this inspection suggests that inappropriate and harmful actions pertaining to the control and remediation of mold growth continue and many of the 2019, 2021, and 2022 recommendations were largely ignored,” Gordon Mycology wrote. “These inactions have caused the mold problems to become worse in certain areas observed and potentially more harmful to those who work and live in the facility.”

The Gordon Mycology report concluded the facility "should not be occupied."

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Inadequate access to mental and physical health care

From delays in treatment, lack of responsiveness to patient complaints, and inadequate responses to less common medical issues, the Disability Law Center report raises significant concerns about Bridgewater State patients' access to appropriate mental and physical health care.

One patient’s testimony, which was included in the report, provides a disturbing look at conditions for patients who suffer from chronic or severe medical issues.

An un-named patient alleges that it took hospital staff months to obtain his recommended medication for a chronic inflammatory skin condition that causes large and painful cysts. Despite the potential for the condition to lead to sepsis without successful treatment, staff refused to let the patient see his regular dermatologist, did not provide the recommended medication until five months after his admission, and did not administer the medication as the doctor recommended. At the same time, staff repeatedly made fun of the patient’s cysts and a former employee went so far as to spray the patient with industrial cleaning fluid, according to the report.

Access to mental health care was not much better, the report said.

Another patient who admitted to hearing voices and having visions told the Disability Law Center that he had not spoken directly with a doctor since he arrived on the unit five days earlier. He was locked in his cell, only getting out for two to three hours per day, had medication for his hallucinations discontinued due to a side effect, and when the patient requested to see the crisis team, a nurse informed him that she would "look into it."

“This young man came to BSH believing it was a hospital only to find that he could not access treatment or kindness and would ultimately leave BSH worse than when he arrived – robbed of hope, further destabilized, and still experiencing serious symptoms of a mental health condition,” the Disability Law Center wrote.

Calls to shutter Bridgewater State Hospital

“With another reporting period closed, DLC repeats our urgent call for the Commonwealth to transfer oversight of the BSH population from the DOC to the Department of Mental Health (DMH) and to construct a new psychiatric hospital,” the DLC concluded in their report.

"Massachusetts must cease involuntarily committing people with complex mental health needs and disabilities to a state prison facility where they will foreseeably face countertherapeutic conditions and suffer violations of their legal rights by those meant to provide them treatment," they continued.

“DLC urges the Commonwealth to take action to ensure that all individuals with mental health disabilities who are involuntarily committed for psychiatric evaluation and treatment in our state have access to appropriate services in a therapeutic environment,” said Disability Law Center Executive Director Barbara L’Italien. “This cannot be true while BSH remains open.”

What does the Department of Correction say?

In a Jan. 4 letter to DLC included in the report, Department of Correction Commissioner Carol Mici said the department retained a qualified mental health professional to oversee service delivery as well as an independent expert, Dr. Debra Pinals, to review practices at the hospital.

Mici also said the facility has taken steps to ensure uses of restraints "are both accurately tracked and utilized appropriately," and that Wellpath submitted revisions to its policy governing seclusion, restraint and involuntary psychotropic medication.

"The Massachusetts Department of Correction, in coordination with our external medical provider, remains deeply committed to ensuring that patients with complex needs who require strict security hospitalization receive the highest quality of person-centered and trauma-informed care," a DOC spokesperson told the State House News Service Wednesday. "The DOC has enhanced staff training and increased independent oversight by behavioral and mental health experts who have reviewed policies to ensure alignment with Department of Mental Health policies and regulations. These significant measures are designed to ensure the well-being and safety of those living and working at Bridgewater State Hospital."

With reporting by the State House News Service

This article originally appeared on The Enterprise: Report slams Bridgewater State Hospital for 'abuse' and 'violations'