A Critical Examination of State Agency Investigations into ...
A Critical Examination of State Agency Investigations into ... A Critical Examination of State Agency Investigations into ...
The alleged abuse began in September 2004, one year and eight months afterJonathan entered the Anderson School. Although Jonathan had made some progress atthe school, he continued to display aggression toward others, and he often would throwhimself to the floor or run away from the staff members who were supervising him.Jonathan had begun to remove his clothes at inappropriate times, and he frequently soiledhimself. In an attempt to manage some of Jonathan’s maladaptive behaviors, theAnderson School implemented a “planned ignore” treatment plan that instructed staff toignore bad behaviors and reinforce good behaviors. Despite the implementation of thetreatment plan intended to address these behaviors, Jonathan’s maladaptive behaviorsescalated. Sometimes this resulted in staff members “ignoring” Jonathan for most of aday. Ultimately, Jonathan was confined to his room for extended periods while he wasacting out. Access to regular meals became contingent on his displaying cooperativebehaviors. As a result, Jonathan frequently was not provided regular meals because ofhis behaviors. During this period, a nurse at the Anderson School documented, “It isbecoming more frequent that [Jonathan] will not [get dressed to eat] and longer periods oftime are occurring without nourishment.” Although provisions were eventuallyformalized for Jonathan to receive substitute food items when he was not provided hisregular meals, it was impossible to determine Jonathan’s overall food intake or what foodwas offered because documentation was poor or missing altogether. Further, theAnderson School did not have this meal plan reviewed by a dietician until 25 days afterthe plan was implemented.While in his room, Jonathan was not permitted to have toys, books, or other itemshe enjoyed. Several weeks after the initial treatment plan was implemented, his window2
was covered with frosted paper to prevent him from looking out, and eventually staffmembers were instructed to limit Jonathan’s communication with his parents.On October 22, 2004, Jonathan’s parents removed him from the Anderson Schooland the next day, brought him to a hospital emergency room for an examination. TheCareys alleged that Jonathan had been neglected, and that he was malnourished as aresult of the school’s practice of limiting his access to meals. They also alleged thatJonathan’s treatment plan was modified without their consent, that he had been forced toremain in his bare room for extended periods, and that he was left to lie naked on a urinesoakedbed. Anderson School records indicate that Jonathan sustained multiple bruisesduring this period, and Jonathan’s parents suggested that these were the result of physicalabuse. The Careys further alleged that the school had allowed Jonathan to eat dairyproducts, in violation of his prescribed diet, and that he had missed multiple days ofschool. As required by law, the emergency room nurse reported the child abuseallegations to the State Central Register of Child Abuse and Maltreatment.The Inspector General’s review covered Jonathan’s care at the Anderson School,which began in January 2003 and ended in late October 2004, and the investigative andreview activities that followed from late October 2004 through 2006. To address theCareys’ allegations, the Inspector General devoted significant resources to thisinvestigation. Beginning in March 2007, attorneys, auditors, and investigators werededicated to this project for approximately a one-year period. Over 75 interviews wereconducted with pertinent staff, executives, and other relevant witnesses and over 25,000pages of documents were received and analyzed by the Inspector General’s Office. TheInspector General’s office also devoted over 10 hours of in-person interview time with3
- Page 2 and 3: Pursuant to Executive Law § 53, th
- Page 4 and 5: INVESTIGATION BY THE TACONIC REGION
- Page 8 and 9: Michael and Lisa Carey. Along with
- Page 10 and 11: The Careys filed a complaint with t
- Page 12 and 13: The Taconic Regional Office’s Inv
- Page 14 and 15: egulatory violations identified in
- Page 16 and 17: compared to consumers in state-oper
- Page 18 and 19: determined that Jonathan’s treatm
- Page 20 and 21: Statements from CQC executives and
- Page 22 and 23: investigating agencies or the Gover
- Page 24 and 25: 7. There is no justification for a
- Page 26 and 27: Legislative RecommendationThe Inspe
- Page 28 and 29: and give positive reinforcement for
- Page 30 and 31: separate reports. Taconic’s was i
- Page 32 and 33: 4. Did the investigating agencies e
- Page 34 and 35: in the Department of Special Educat
- Page 36 and 37: III. BackgroundNEW YORK STATE SERVI
- Page 38 and 39: abuse or maltreatment within New Yo
- Page 40 and 41: certain OMRDD-certified facilities,
- Page 42 and 43: instances in which the Anderson Sch
- Page 44 and 45: appropriateness of the Dutchess Cou
- Page 46 and 47: Diagram of the Anderson School camp
- Page 48 and 49: Additionally, the Mental Hygiene La
- Page 50 and 51: Among the protections offered in th
- Page 52 and 53: To ensure the safety of the residen
- Page 54 and 55: The reports are shared with the fam
was covered with frosted paper to prevent him from looking out, and eventually staffmembers were instructed to limit Jonathan’s communication with his parents.On October 22, 2004, Jonathan’s parents removed him from the Anderson Schooland the next day, brought him to a hospital emergency room for an examination. TheCareys alleged that Jonathan had been neglected, and that he was malnourished as aresult <strong>of</strong> the school’s practice <strong>of</strong> limiting his access to meals. They also alleged thatJonathan’s treatment plan was modified without their consent, that he had been forced toremain in his bare room for extended periods, and that he was left to lie naked on a urinesoakedbed. Anderson School records indicate that Jonathan sustained multiple bruisesduring this period, and Jonathan’s parents suggested that these were the result <strong>of</strong> physicalabuse. The Careys further alleged that the school had allowed Jonathan to eat dairyproducts, in violation <strong>of</strong> his prescribed diet, and that he had missed multiple days <strong>of</strong>school. As required by law, the emergency room nurse reported the child abuseallegations to the <strong>State</strong> Central Register <strong>of</strong> Child Abuse and Maltreatment.The Inspector General’s review covered Jonathan’s care at the Anderson School,which began in January 2003 and ended in late October 2004, and the investigative andreview activities that followed from late October 2004 through 2006. To address theCareys’ allegations, the Inspector General devoted significant resources to thisinvestigation. Beginning in March 2007, attorneys, auditors, and investigators werededicated to this project for approximately a one-year period. Over 75 interviews wereconducted with pertinent staff, executives, and other relevant witnesses and over 25,000pages <strong>of</strong> documents were received and analyzed by the Inspector General’s Office. TheInspector General’s <strong>of</strong>fice also devoted over 10 hours <strong>of</strong> in-person interview time with3
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