LINCOLN, Neb.—Abuse and neglect continued to be reported at the Beatrice State Developmental Center last year even after the state promised to do more to protect residents, according to a new report released Tuesday.
The state’s promise to improve the center was part of a settlement the state reached with the U.S. Department of Justice in June after federal investigators found hundreds of cases of abuse.
But the independent expert assigned to review whether the center is meeting terms of the settlement said problems remain.
“I believe there are still issues related to protection from harm at BSDC,” expert John McGee wrote in the report.
State officials declined to comment until after they review the report.
The Justice Department investigation uncovered about 200 cases of alleged neglect and abuse at the center from late 2006 to late 2007 and concluded the center had a “cultural undercurrent that betrays human decency at the most fundamental levels.”
From July through November of last year, the new report cites 42 reported case of abuse and neglect at the center. There were also 42 staff suspensions and firings over the same period, according to the report.
McGee’s report is not an unqualified indictment of the center: He often praises the state’s efforts to improve conditions and lauded the decision last week to move out medically fragile residents.
McGee is supposed to do more reviews of the center under the agreement with the Department of Justice. About 200 residents remain at the center that is home to people with disabilities ranging from Down’s syndrome to severe autism. Most of the residents are mentally retarded.
“We are just at the beginning, but the beginning is good,” says the report. “Now the challenge is to ensure each person adequate, appropriate care, services and supports.”
Among the examples of alleged neglect the expert cited in the report from July through November was a resident who suffered two fractures and was allowed to continually slap her own face. The injuries and self-abuse “contradict an adequate standard of care, and equate with a culture of negligence that goes contrary to the agreement,” McGee wrote in the report.
Repeated failures to meet federal standards of care prompted the federal government to decertify the center and yank its $29 million in annual, federal funding. But both those actions remain on hold as the state appeals the decision.
Chances of the state winning the appeal appear slim following a declaration last week by the state’s chief medical officer that the center was too dangerous to hold “medically fragile” people. About 45 such residents are now at hospitals and the state hopes to move them into community-based programs.
Transferring residents out of the center is a key piece of the state’s broader plan to eventually comply with federal standards, and officials believe that will improve care in Beatrice and increase the staff-to-resident ratio.
McGee generally agrees with the effort to move people into programs, but questioned whether the programs have the capacity to handle more people.
Too many residents have been moved to nursing homes or institutions, which McGee suggested may violate terms of the settlement agreement because residents are supposed to be placed in settings where they have the most freedom.
“I am deeply concerned by the placement of BSDC residents into nursing homes and other settings that might not provide the necessary supports and protections contemplated in the settlement agreement,” McGee wrote. “The transfer or placement of BSDC residents into nursing homes or large (institutions) is quite troubling.”
McGee said the state seems to be moving away from nursing-home placements. From July through January, just four residents were moved to nursing homes.
The report also highlights a possible pitfall of rushing residents into community programs. McGee said in the report he was “aghast” at the lack of safeguards to ensure that a resident with a history of sexual assaults did not re-offend in a community program.
The resident, who the report refers to as “Jake,” was considered at risk of sexually preying on vulnerable people. But he was still cleared to go to a community program that had goals of limiting to five a month his acts of aggression, and two incidents per month of breaching “social/physical boundaries.”
McGee said he asked the state to postpone the placement, and “Jake” was eventually moved to a setting with more safeguards.
“Jake is an example of the high-risk nature of a small minority of BSDC individuals with documented histories of sexual abuse…several warning signs call for a more deliberate and judicious placement process.”
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