NEW HAVEN — An investigation by Disability Rights Connecticut has found that the Connecticut Mental Health Center failed to investigate sexual assault claims, restrained or secluded patients without proper documentation or monitoring, and allowed mice to infest its facility. 

The center, run by the Yale School of Medicine and the state’s Department of Mental Health and Addiction Services, is a 20-bed facility for patients suffering from serious mental illnesses like schizophrenia and post-traumatic stress disorder, sometimes combined with substance abuse. 

“DRCT’s systemic findings uncovered a pervasive culture of DMHAS’ and CMHC’s failure to adequately protect and treat patients under its care,” the report reads.  

The investigation outlined in the report spanned nearly three years — from April 2021 to February 2024. The organization looked at the records of 14 patients at the facility, visited six times and interviewed staff and patients.

Rachel Mirsky, the supervisory attorney at Disability Rights Connecticut, told CT Examiner that the organization decided to investigate the center after receiving multiple complaints about the conditions there. 

Abuse incidents 

The report describes an incident where a 25-year-old woman was sexually assaulted by a male patient on two different occasions in the spring and summer of 2021. The facility allegedly failed to investigate the assaults. The woman, who had been diagnosed with chronic post-traumatic stress disorder as well as having a borderline intellectual disability, left the facility after three months. 

Another woman, 23, who came into the facility with post-traumatic stress disorder from childhood sexual abuse, was allegedly assaulted three times by a male patient over the course of six months. None of the instances were investigated, the report claims. When it was time for her to leave the facility, the report states she was discharged to her family despite having told her treatment team that she had been abused by her brother, who also lived there. She returned to the center a week later after relapsing into substance abuse, and was alleged to have been sexually harassed on a number of occasions over the following six months. None of those allegations were reported or investigated, according to the report.

The report also found that a number of patients were denied essential care, including the lack of assigned psychologists and the absence of plans to support positive behavior. The report noted that the 23-year-old woman was prescribed emergency psychotropic drugs — chemical restraints — 14 times and was physically restrained on one occasion, but never received a psychological assessment or behavior plan. 

The center is also accused of failing to consistently document the use of restraint and seclusion on patients, which is meant to be used only when the person or others in the vicinity are in immediate physical danger, and requires a doctor to sign a form indicating that restraints are necessary. According to the report, this documentation was regularly missing.  

A 31-year-old man diagnosed with schizophrenia was admitted to the center in 2019. After about a year in the facility, he was discharged to a group home, where it is alleged that he attacked a staff person and another resident. He was sent to the emergency room and then returned to the center. 

“The [center] social worker documented that shortly after his readmission to [the center], the father of John Doe #1 asked the social worker what would be different about his treatment this time and stated that John Doe #1’s previous stay with [the center] had lasted for one year and that he was discharged unchanged,” the report read.  

During the 32 weeks he remained at the center, the man was physically restrained 14 times, chemically restrained 16 times and placed in seclusion six times, according to the report. The documentation required for these restraints and seclusions was allegedly incomplete or missing in all of these instances. 

According to the report, the man was sexually abusive toward staff and other patients at least 50 times during his stay, but none of those instances triggered an investigation. 

Over reliance of restraints on psychiatric patients rather than treatment was also reported in a 2019 investigation that Disability Rights Connecticut conducted on Whiting Forensic Hospital in Middletown.

In addition to unreported abuse and instances of restraints, the report on the Connecticut Mental Health Center found that certain patients were also regularly missing their clinical groups.

The report also criticized the facility itself, which had been beset by a mouse infestation. In September 2022, the housekeeping staff said 25 mice were captured in traps over one weekend. 

“Documentation indicated that mice were present in the kitchen/dining area, lounges, and patient bedrooms. On February 21, 2024, staff reported that even though the exterminator visited the facility three times a week, they continue to see mice in patient living areas, especially at nighttime. More is needed to address this chronic and unsanitary situation,” the report noted. 

The building also contains 63,000 square feet of asbestos under the floor tiles which has not yet been remediated. 

State response 

Chris McClure, spokesperson for the Department of Mental Health and Addiction Services, told CT Examiner in a statement that the Connecticut Mental Health Center and all its facilities meet the “exacting and precise objective standards of care” required by the Joint Commission, and that client care was their highest concern. 

“While we appreciate the hard work and input of DRCT, and while we continue to review their report, the agency has numerous concerns with DRCT’s findings and recommendations; which include subjective criteria, calls for systems change when robust risk management, quality assurance, and critical incident reporting are already in place, and citation of isolated events that have since been remedied,” McClure said. 

But Mirsky told CT Examiner that, while the department says it has oversight from the Joint Commission, which accredits and sets standards for these facilities, she questions the quality of the Joint Commission’s assessments.  

“We have looked at reports from the Joint Commission and there we have found things that they did not find,” Mirsky said.  

McClure noted that the department disagreed with the organization’s findings and said senior leadership was “made available to DRTC throughout to discuss the material.”

But Disability Rights Connecticut is now asking for an outside agency to oversee the center and other facilities run by the Department of Mental Health and Addiction Services. 

Of the six inpatient psychiatric hospitals that the Department of Mental Health and Addiction Services runs in Connecticut, only one — Whiting Hospital — has independent oversight from the Department of Public Health, Mirsky explained.

“If [the Department of Public Health] or a similarly situated agency went in on a regular basis … people would have the ability to file complaints with them at any time,” Mirsky said. “If they get complaints, they can say, alright, we’re going to go in, we’re going to investigate. That’s not happening. We went in to investigate because no one else really is.” 

The organization is also asking for the creation of a system to monitor reporting and investigations of abuse and neglect claims, a system to monitor quality of care and require reviews of restraints and seclusions. 

“CMHC and its staff remain focused on the safety and care of their patients, engaging in ongoing monitoring and quality improvement for the clinical care they deliver. The center takes all feedback seriously and employs it in its ongoing efforts to improve the care that it delivers,” Yale said in a statement. 

Maureen Lyons, of the Joint Commission, told CT Examiner that the commission reviews complaints. Although the commission works with organizations like CMHC to “identify potential risks to patient safety and improve quality of care,” only a “governmental entity” can require a facility to shut down, she said.