A Critical Examination of State Agency Investigations into ...

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document indicated that Jonathan ate “2 bagels with mar., 2 sausages, 1 hash brown, 1bowl of Golden Grahams with soymilk, 8 ounces soy,” on October 11, 2004. Othernotations indicated that Jonathan ate very little or refused to eat the substitutes.In addition, the Inspector General’s office learned that Jonathan also consumedother food, known as “edible reinforcers,” which were not documented by staffthroughout this period. Regarding the amount of undocumented “edible reinforcement”that Jonathan would typically consume, one direct care staffer stated:We would have it [Corn Pops] usually in baggies, in sandwich baggies,full, and like, usually for the days that I did get him to go to the School thebag would be gone. You know, because it’s constant giving him one at atime.Additionally, this staffer reported to the Inspector General that Jonathan, in adeviation from the Behavior Support Plan instructions, was allowed to eat some regularmeals at the table when other residents were not present, even though he was not fullydressed.A logbook entry from October 9, 2004, reads: “JC has spent his entire day inroom w/no clothing on. He is refusing to use toilet.” That day, a portable toilet wasplaced in his bedroom to assist with toileting during the planned ignores.The Anderson School staff gave two basic explanations why they did not bringfull meals to Jonathan’s room. The Director of Children’s Residential Services reportedthat “full meals were not offered in Jonathan’s room due to safety and hygiene issues.”She further added, “We didn’t want to take the chance that he would be throwing hisfood, smearing his food, doing whatever with it and then not have a good environment.”70
The second explanation was that allowing Jonathan to eat his regular meal in hisbedroom would reinforce his behavior of staying naked in his bedroom when the goalwas for him to come out and eat with the other residents. “If meals were brought to himin that state [naked], he would never get dressed,” a nurse stated. The second explanationappears more plausible because they were allowing him to eat meal substitutes, such assoy yogurt, in his bedroom.On October 10, 2004, Michael Carey visited his son. He stated that he foundJonathan covered with bruises, lying on his bed atop a sheet that was “soaked” in his ownurine. He added that there was a staff member posted “like a guard” outside his son’sroom with the door ajar a few inches. He indicated that he helped clean and dress his sonand they went to a McDonald’s restaurant, where his son ate an extremely large meal. “Idon’t think I ever saw him eat that much. He just wanted to eat and eat and eat, still notreg istering to me just, just you know, and I didn’t know what to make of the wholething.”An October 11 Behavioral Report Form revealed that Jonathan’s behavior wasfluctuating. It noted that “the dynamics and intensity…was much different than onFriday [October 8]. He was laughing a lot and trying to get staff’s attention more.”Jonathan’s logbook stated that Jonathan ate breakfast and lunch and seemed very happyduring the first shift. Later that day, however, reports showed that Jonathan flopped onthe floor, urinated in his pants, threw his shoes and was aggressive.In response, the Anderson School obtained an emergency psychiatric medicationreview and Jonathan’s medication was boosted to address his behaviors. Lisa Carey was71
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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
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
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 76 and 77: notified and she consented to the m
Page 78 and 79: The Anderson School Executive Direc
Page 80 and 81: naked to prevent him from leaving t
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
Page 98 and 99: INVESTIGATION BY THE TACONIC REGION
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 106 and 107: an entry on an October 4, 2004, Beh
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
Page 116 and 117: acknowledged there was a “propose
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
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additional information was availabl
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his supervisor at the time, then-Ar
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that is absent from the Statement o
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clinical director role, psychiatris
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the table contingent on appropriate
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Former Regional Director Articola s
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BruisingAlthough the Careys noted t
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Seclusion / unauthorized time-out /
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monitoring or supervision by clinic
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Investigation of complaint by an in
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and included supporting documentati
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think they wanted him to have the r
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Inaccurate Information Provided to
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this allegation. The letter was tra
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While reports indicated that the An
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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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