A Critical Examination of State Agency Investigations into ...

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