A Critical Examination of State Agency Investigations into ...

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CQC investigator’s notes reflected that the examining nurse described Jonathan asappearing “thin but not malnourished.” She also told CQC that the Careys hadcomplaints about “possible malnutrition, abuse, and neglect.” She added that Michaeland Lisa Carey had informed her that Jonathan’s “demeanor has changed significantly.”Numerous records reviewed by the Inspector General’s Office revealed thatJonathan was admitted to the Anderson School weighing 61 pounds at a height of 53inches. During his placement there, Jonathan grew three inches to 56 inches. Recordsfrom the emergency room visit immediately following his removal from the AndersonSchool listed Jonathan’s weight as 70 pounds. Thus, Jonathan grew three inches andgained approximately nine pounds while at the Anderson School. According to weightcharts provided by the Center for Disease Control and Prevention, Jonathan’s weight wascategorized as “a healthy weight” throughout the crisis period in September and October2004.On October 25, 2004, at a Bethlehem School District CSE meeting, the Careysread a 16-page handwritten statement outlining their numerous complaints against theAnderson School and requesting investigations. According to the statement, the Careysalleged the following (in summary):1. Jonathan was not provided with a casein-free diet.2. “Food was repeatedly withheld from Jonathan daily, over a period ofweeks, if he did not comply with staff directives to get dressed.”3. Food was used as part of Jonathan’s behavior plan and as “discipline”and the Careys did not “agree with,” or “consent” to, this technique.4. Jonathan lay “on his bed naked all day” and “was not allowed out ofhis room unless he would comply with the directive to get dressed.”5. These conditions were reportedly witnessed by the Careys on threeoccasions (October 10, 16 and 18, 2004) when they found Jonathan86
lying naked, uncovered, on his bed. On two of those occasions,October 10 and 16, the mattress was soaked with urine. The Careysbelieved that Jonathan had been left to lay naked for periods of 36hours or more.6. Jonathan’s “body was covered with extensive bruises” and the Careyswere told it was due to Jonathan “trying to get out the front or backdoor of the cottage repeatedly.”7. Jonathan missed between “one and two weeks of school. ”8. The Careys did not agree with, or consent to, “the school’s decision, tosuspend our right as Jonathan’s family to visit him” or to “restrict ourphone contact with our son, and the staff working directly with himeach day, so severely.”9. A “point-of-contact” person was implemented by the AndersonSchool, thereby filtering the Careys’ communication with their son.The Careys’ lawyer sent a letter dated November 1 with a copy of the statement tothe Taconic regional office. CQC also received a copy of the letter and the statement.SUBSEQUENT RESIDENTIAL PLACEMENTSWhile Jonathan’s experiences after the October 25 meeting are not the focus ofthis investigation, they merit mention. Records show the following:Jonathan lived with his parents and younger brother for several months, enteringthe Kevin G. Langan School in Albany as a day student in early 2005. In October, hisaide-to-student ratio was increased from one aide to two. Several attempts to findresi dential placement failed. After one interview with Jonathan, St. Colman’s in Lathamstated that it could not address his aggressive behaviors and that his presence there wasunsafe for children and staff.Subsequently, Jonathan was treated by a psychiatrist during sessions spanning theperiod August 18, 2005 to October 23, 2006. During his treatment, the psychiatristauthored a June 22, 2006 letter to then-OMRDD Commissioner Thomas Maul in which87
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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
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 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
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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 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
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 /
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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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