http://www.denverpost.com/2016/09/27/pueblo-home-for-disabled-oversight-deficient/
Abuses at a Pueblo center for people with severe intellectual disabilities included a resident performing a sexual act in exchange for a soda and another burned with a blow dryer in an attempt to raise her body temperature, according to a federal report obtained by The Denver Post.
A group of men, some who are nonverbal, had words scratched into their skin, including “die,” “kill,” and “I’m back,” federal investigators found. When questioned, three staffers said they believed the markings were the result of “paranormal activity.” Staffers had posted photos of the etchings on social media, the report said.
The incidences of abuse at the Pueblo Regional Center — one of three centers in Colorado that are home to adults with developmental, physical and intellectual disabilities — occurred before November 2015. Yet federal investigators who visited the home in April found safety protocols still lacking. They notified Colorado Medicaid officials in an August letter that they were enacting a moratorium on new residents at the center and that Colorado must repay millions of dollars in Medicaid funding.
“These are some of our most vulnerable people in Colorado,” said Stephanie Garcia, executive director of The Arc in Pueblo, a nonprofit advocacy group for people with developmental disabilities. “To read some of the things going on, it’s shocking.
“It’s much worse than we thought. It seems like every system of oversight failed. We should have checks and balances in place,” she said.
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In the last 18 months, state officials conducted “intense retraining” of staff, have visited the Pueblo center 13 times and began scrutinizing its reporting of critical incidents almost daily, the state’s health care policy and financing executive director, Susan Birch, said Tuesday.
Federal officials blasted state oversight, saying state Medicaid officials did not properly investigate despite “numerous severe incidents reported,” and that the Pueblo center “has a history of not properly reporting or responding to incidents.” The state did not “identify the trends, problematic practices or provide follow-up for the incidents,” the report said.
Birch said the staff in her department “is only as good as the information that they have to work with,” adding that critical information was not reported by the Pueblo center to the state or the local community-centered board.
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In April 2015, state human services officials conducted “body audits” on 62 residents of the Pueblo center after abuse allegations. The audits were done without consent or knowledge of the guardians, prompting a backlash from legislators, who wrote a letter to Gov. John Hickenlooper calling for a change in leadership at the state’s human services department. The state health department determined the body checks were a violation of residents’ rights.
Pueblo County sheriff’s officials also investigated at least “19 complaints of abuse, maltreatment and unlawful sexual contact,” according to the federal report. In some instances, the sheriff’s office substantiated abuse that the center did not, including the allegation of sexual abuse. In at least one case, criminal charges were filed after allegations of physical assault. The director of the center resigned in May 2015, saying the reports of abuse were unfounded. Eight employees resigned or were terminated, and another eight were disciplined.
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The federal investigation included a four-day visit to Pueblo five months ago. Among the issues discovered during that April visit: improper use of physical restraints that “could have resulted in serious injury,” and bruising and rug burns on a resident.
Federal officials determined that numerous incidents “that gave rise to the body audits” were substantiated and “clearly posed a risk to the health and safety” of residents. Also, their on-site review “revealed that a number of serious incidents have continued to occur.”
The federal report provides new details on the abuse, including that three residents had died, two from bowel obstructions and one who collapsed and was not given life-saving care because a staffer mistakenly thought there was a “do-not-resuscitate” order. A staff resident locked a resident outside in the cold for two hours as punishment, and in another case, a staffer assaulted multiple “vulnerable” individuals by hitting their legs and arms, covering one person’s head with a blanket and threatening to “slash the throat” of another. Criminal charges were filed against that staff member. In another incident, an intoxicated staff member drove a resident to a doctor’s appointment, the federal report says.
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The federal report adds that 90 percent of the Pueblo center’s residents are prescribed psychotropic medications, but the center has failed to ensure residents and their guardians received sufficient information necessary for informed consent to take the medications. In addition, the use of those medications was not properly monitored, the report found.
State Rep. Dave Young, a Greeley Democrat and also a member of the joint budget committee, has a sister who lives at the center in Pueblo. He said he’s concerned because the federal report shows the state still hasn’t fixed staffing issues that legislators raised concerns about a year ago.
For his sister, the lack of oversight of her psychotropic medications could prove fatal since she recently had a liver transplant, Young said. He added that expecting those living at the center to find adequate care in community residential settings won’t work for everyone. His sister struggled with 20 residential placements in one year before finally getting into the Pueblo center.
“When we have dramatic changes in services to such a vulnerable population, gaps in service can have massive impact on their safety,” Young said. “They have the potential to become life or death situations for these people.”
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