A Critical Examination of State Agency Investigations into ...

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an entry on an October 4, 2004, Behavioral Report Form. The directcare staffer who completed this report wrote, “I feel that it’s abusive torefuse food for this reason,” referring to directives to staff to withholdregular meals from Jonathan when he did not get fully dressed to dinewith the other residents.27 Regulations require that allegations of abusemust be immediately reported to OMRDD and within 48 hours toCQC.• The Taconic office’s investigation disconfirmed allegations thatJonathan was allowed or forced to lie on his bed naked for anyextended period of time or that the bruises on Jonathan’s body werethe result of physical abuse.Inspector General’s Findings Regarding Investigative ReportOf the two findings that the Taconic regional office disconfirmed, the InspectorGeneral determined that the finding that Jonathan was not left to lie naked on his bed wasin conflict with the evidence. Regarding the other allegation that Jonathan’ s bruises werea result of physical abuse, the Inspector General found no evidence to contradict thereport’s conclusions that Jonathan’s bruises were the result of “the physical interventionsemployed and the defiant non-compliant behaviors he manifest.”Finding that Jonathan was not left to lie naked on a bed wet with urineThe December 1, 2004, report of the Taconic regional office’s investigation statedthat, “there is no evidence to support the allegation that Jonathan was allowed or forced27 This staff person ultimately deviated from the Behavior Support Plan and allowed Jonathan to eat at thetable, even though he was not fully clothed. When interviewed by Inspector General’s Office, this directcare staff member stated that he was subsequently reprimanded for having made this accommodationbecause he was not “part of the team.” He went on to explain his conduct to the Inspector General: “Therewas no negative behavior [by Jonathan] and he was sitting there like, I want food…I felt I should give himthe food at that point. That’s why I deviated independently from this new plan because I was going withmy gut… I have never encountered another behavior as intense as [Jonathan’s behaviors]...this is like aspecial situation…I wanted to know if I could hold back the breakfast and I was told yes, I can and Ishould. I went against the plan, so I was talked to about it…that was me not being a part of the team…so Iremember it more because I was reprimanded [by a supervisor].” He added that after he wrote theBehavioral Report, Jonathan’s Behavioral Support Plan changed, allowing staff to offer him substitutes forhis regular meal.102
to lay [sic] on his bed naked for any extended period of time.” The report continued tosay that there were “no reports of Jonathan lying on a urine-soaked bed for an extendedperiod of time, although an increase in the frequency of urination was noted.”The Inspector General’s Office found sufficient evidence to support a finding thatmultiple staff members and Jonathan’s own parents observed Jonathan lying naked in hisown urine on several occasions, although for unknown durations.Michael Carey reported to the Taconic regional office that he had witnessedJonathan lying naked in his room on October 10, 16, and 18, 2004, when he arrived at theAnderson School to visit his son, and, on two of those occasions, the bed was wet withurine.Michael Carey’s claims are supported by the testimony of two Anderson Schoolemployees who were interviewed during the Taconic regional office’s investigation. Theresidential coordinator reported that she had observed Jonathan lying on his urine-soakedbed with no sheet. Another direct care staff member stated he observed Jonathan lyingon his bed once after Jonathan had urinated on it, and he was told by other staff they hadalready changed the bed and to keep sheets off the bed for hygiene reasons.In addition to the direct witness accounts to his condition, documents obtainedduring the Inspector General’s investigation also indicate that Jonathan’s sheets were notchanged regularly. A handwritten document entitled “New Protocol,” dated October 13,2004, advised staff to “Change Jonathan’s sheets once in the a.m. when he gets up (if bedis wet). If he wets again – take sheets off and don’t put clean ones on until he leaves forSchool. If he doesn’t go to School – leave bed unmade (until bedtime). If Jonathancomes home from School and wets the bed – strip the bed until bedtime.”103
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Pursuant to Executive Law § 53, th
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INVESTIGATION BY THE TACONIC REGION
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The alleged abuse began in Septembe
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Michael and Lisa Carey. Along with
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The Careys filed a complaint with t
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The Taconic Regional Office’s Inv
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egulatory violations identified in
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compared to consumers in state-oper
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determined that Jonathan’s treatm
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Statements from CQC executives and
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investigating agencies or the Gover
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7. There is no justification for a
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Legislative RecommendationThe Inspe
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and give positive reinforcement for
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separate reports. Taconic’s was i
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4. Did the investigating agencies e
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in the Department of Special Educat
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III. BackgroundNEW YORK STATE SERVI
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abuse or maltreatment within New Yo
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certain OMRDD-certified facilities,
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instances in which the Anderson Sch
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appropriateness of the Dutchess Cou
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Diagram of the Anderson School camp
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Additionally, the Mental Hygiene La
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Among the protections offered in th
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To ensure the safety of the residen
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The reports are shared with the fam
Page 56 and 57: esident’s physical condition, inc
Page 58 and 59: He could also become physically agg
Page 60 and 61: RESIDENCY AT THE ANDERSON SCHOOLIn
Page 62 and 63: Shortly after his admission, Jonath
Page 64 and 65: a snack such as cereal or verbal pr
Page 66 and 67: weekend, his behavior was so bad, s
Page 68 and 69: Experts retained by the Inspector G
Page 70 and 71: The October 9, 2004, Anderson Schoo
Page 72 and 73: eally losing it, going bananas basi
Page 74 and 75: document indicated that Jonathan at
Page 76 and 77: notified and she consented to the m
Page 78 and 79: The Anderson School Executive Direc
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Page 82 and 83: Anderson School Weekly Body Check F
Page 84 and 85: continues. Does he take a multivita
Page 86 and 87: Executive Director stated that arou
Page 88 and 89: OMRDD regulations, OMRDD called the
Page 90 and 91: CQC investigator’s notes reflecte
Page 92 and 93: the psychiatrist wrote (in part),
Page 94 and 95: V. State Agency Investigations of A
Page 96 and 97: On October 25, 2004, the Careys att
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Page 100 and 101: are responsible for conducting thei
Page 102 and 103: School policies and procedures. Inv
Page 104 and 105: Taconic Regional Office’s Finding
Page 108 and 109: When questioned about the Taconic r
Page 110 and 111: involved “fully in the program pl
Page 112 and 113: What were the employees doing that
Page 114 and 115: Central Office. Although the Anders
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Page 118 and 119: Taconic Regional Office’s Letter
Page 120 and 121: it is not his office’s policy to
Page 122 and 123: SURVEY BY THE OMRDD CENTRAL OFFICEA
Page 124 and 125: additional information was availabl
Page 126 and 127: his supervisor at the time, then-Ar
Page 128 and 129: that is absent from the Statement o
Page 130 and 131: clinical director role, psychiatris
Page 132 and 133: the table contingent on appropriate
Page 134 and 135: Former Regional Director Articola s
Page 136 and 137: BruisingAlthough the Careys noted t
Page 138 and 139: Seclusion / unauthorized time-out /
Page 140 and 141: monitoring or supervision by clinic
Page 142 and 143: Investigation of complaint by an in
Page 144 and 145: and included supporting documentati
Page 146 and 147: think they wanted him to have the r
Page 148 and 149: Inaccurate Information Provided to
Page 150 and 151: this allegation. The letter was tra
Page 152 and 153: While reports indicated that the An
Page 154 and 155: facilities like the Anderson School
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egistry, and then it seems there wa
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INVESTIGATION BY THE NEW YORK STATE
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target(s) of the complaint engaged
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arely used by CQC to substantiate a
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The second paragraph of the case su
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CQC Director of Quality Assurance a
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primarily to the provision of meals
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interview notes would have been exp
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Jonathan’s “demeanor has change
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that the additional complaints of a
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and aggressive behavior related to
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systemic significance.” In a hear
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• Anderson School did not have co
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Jonathan’s casein-free diet, that
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treatment review to the Careys, the
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Documentation of investigatory acti
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As noted above, Bowser also failed
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did not do a full care and treatmen
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CQC’s progress notes indicate tha
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epeatedly attempted to exaggerate t
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focuses. “We did it at the same t
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ead, “If he wets again - take she
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Although the statement provided to
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The oversight deficiencies were eve
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that OCFS’s rate of indication is
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In the following sections the Inspe
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On at least one previous occasion,
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emotional injury was impossible in
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facility employee and CQC recommend
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Restrictive Statutory LanguageAltho
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ecognizes that the determination of
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CQC policy does not require further
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CQC wrote in its unfounded notifica
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INVESTIGATION BY THE NEW YORK STATE
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develop sufficient evidence to supp
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There is not proper and safe oversi
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the meeting, “We left it with the
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this important matter. Your corresp
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VI. RECOMMENDATIONSThe Inspector Ge
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ehavior management (14 NYCRR § 633
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child in an institutional setting,
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(a) Records and documents pertainin
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(ii) violent behavior exhibited by
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8. Such commissioners shall provide
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plan of prevention and remediation
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the commission as to the implementa
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Agency Responses to the Inspector G
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incident is reported to have occurr
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Page 2Joseph FischJune 5, 2008conta
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Recommendations: The Inspector Gene
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A Critical Examination of State Agency Investigations into ...

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