A Critical Examination of State Agency Investigations into ...

eally losing it, going bananas basically, and that they did not know what to do.” LisaCarey told the Inspector General, “They were not telling us the fullness of what wasgoing on and how bad things had gotten down there until October 9th.” According toMichael Carey, Anderson School administrators told him that they would have Jonathanexamined by a doctor on October 9, 2004, and determine if a hospital visit was necessary.Consistent with Michael Carey’s account, the medical note written on that dateindicated the Anderson School nurse examined Jonathan and found him to be physicallyfine, although she noted that he was “somewhat thinner.” The nurse contacted a doctorfrom a local medical clinic, who reported that no hospitalization was needed from aphysical standpoint unless the bruises were being caused by an unknown problem or ifJonathan was dehydrated, both of which the nurse determined were not the case.The note mentioned that Jonathan would be seen by a physician and would alsoget a psychiatric evaluation. It also was documented that Michael Carey planned to visithis son the next day.Once Anderson School executives formalized a plan to offer substitute foods toJonathan in his bedroom, the nurse filled out a Medication Change/Medical TreatmentNotification form which outlined when and what alternative foods would be offered. Theform stated, “While awake: if meal refused offer soy milk or juice or ice pops or yogurtevery hour. If refused, offer again in one half hour.” The note directed staff to documentJonathan’s food intake. The nurse explained that she wanted to ensure that Jonathan wasgetting nourishment, especially since he had virtually nothing to eat on October 8.The plan didn’t specify the quantities of food to be offered or how staff shoulddocument the information. One staff recalled jotting down Jonathan’s food intake on a68