The state has made progress with the Beatrice State Developmental Center, but in a number of areas, "much remains to be done," an independent expert has reported.
JoANNE YOUNG / Lincoln Journal Star | Posted: Wednesday, July 1, 2009 12:00 am
The state has made progress with the Beatrice State Developmental Center, but in a number of areas, "much remains to be done," an independent expert has reported.
The long-awaited second compliance report from consultant John McGee, assigned to monitor progress at BSDC, outlined lingering concerns and detailed how the institution and other facilities handled care of three residents who died in January.
The 41-page report also made recommendations for changes that are still needed. It covers the period of January through March, with some data updated into early June.
Sen. Steve Lathrop, chairman of a special legislative monitoring committee, said he was expecting more detail in the report, and to see how the state was doing on the 140 promises the state needs to fulfill, according to its agreement with the U.S. Department of Justice.
From what he saw in the report, he said, it is troubling the state has not made more significant improvement after a year.
The state must make the improvements to avoid a federal civil rights lawsuit. The settlement was a response to a justice department report in 2008 that outlined serious neglect and abuse problems at BSDC.
Jodi Fenner, Department of Health and Human Services attorney who will become the interim director of the Division of Developmental Disabilities on Friday, said a lot has changed with BSDC since March. But she agreed there is still progress to be made.
The center expects to lose federal Medicaid funding and anticipates spending the next 18 months to two years working on getting recertified with the federal Medicaid program.
BSDC has gone from 354 clients in October 2007 to 179 as of June 5. Thirteen of 47 "medically fragile" residents, who were removed in February by emergency order, remain in hospitals.
Eleven are in nursing homes, which McGee called a "worrisome concern" that does not comply with the department of justice agreement. But that should improve as the state establishes spots in existing facilities and new ones throughout the state, he said.
Other concerns found by McGee included:
* Physical restraints were used too often.
In fact, while it looked like the use of restraints was being reduced at the end of 2008, it increased in the first quarter of this year, reaching the same levels as mid-2008.
Use of restraints are related to the lack of positive behavioral support, appropriate and adequate psychiatric services, and staff training. And it could produce physical harm in the name of preventing it, McGee said.
* The state has hired a transition specialist, but at times it seems the speed of moving residents to a sometimes ill-prepared community facility "puts the placement before the plan."
The state has made positive steps toward transition planning, McGee said, but much improvement is needed.
McGee said he would be visiting more community providers to monitor placements and the quality of transition plans, and to analyze incidents that have occurred.
The most serious incident with a resident in a community program involved police use of a Taser this spring. McGee called for a thorough investigation of the incident.
It could indicate a lack of staff training, poor supervision or the lack of positive behavior supports, he said.
McGee also discussed the findings of the independent Mortality Review Committee in its analysis of several deaths of BSDC clients.
"The protection of life itself is the state's most fundamental obligation," McGee said. "The highest form of neglect is the occurrence of any preventable death."
On the death of Kyle Krutz, 29, on Jan. 24, the committee found no apparent preventable causes of illness or death, but found other issues.
The resident's allergy to Vancomycin was noted prominently on his Beatrice Community Hospital emergency intake sheet, but he was given the antibiotic at the hospital anyway. Although the error was not made at BSDC, the committee said, it was an extension of the center's responsibility to monitor each resident's well-being.
There were several instances of Krutz's inadequate care at BSDC, the committee said. It recommended clear medical/social summaries on each patient, and quarterly reviews of nursing plans. It also recommended a tag or card accompany each resident that goes to the hospital noting any allergies and types of allergic reactions.
A resident who died Jan. 4, Craig Watkins, 55, was said to have died of pneumonia. Although he did not have an autopsy, a Beatrice Community Hospital radiologist said X-rays indicated congestive heart failure, rather than pneumonia.
That might have been a reversible condition, the committee said. But decisions were made on a "do not resuscitate" order without the resident's guardian having necessary information, either at BSDC or the hospital, the report said.
"We are concerned that the care was less assertive in a situation where a terminal condition was not identified," Mortality Review Committee members said.
The committee found that a more thorough planning process, with opportunities to discuss advance care directives, would have been helpful.
McGee's medical consultants also found that in general, the "do not resuscitate" protocol appeared to be used "often and perhaps with insufficient informed consent."
The committee also examined the death of Olivia Manes, 18, who the state has admitted received inadequate care. Her death prompted the move of the medically fragile patients.
McGee said that although it was unfortunate the state had to invoke an emergency medical order to move medically fragile patients, HHS showed leadership, creativity and courage in doing so.
Fenner said that in the past three months, the state has made progress in:
* Improving medical support for BSDC residents and the "very important" transition process.
* Reconfiguring the BSDC management team and conducting a nationwide search for a new director at BSDC.
* Conducting comprehensive assessments of 200 individuals related to their current needs. They should be fully completed in the next month or two, Fenner said.
* Improving staffing and reducing mandatory overtime, which helps with staff morale, performance and retention, she said.
* Reducing crowding in housing units, giving clients better supervision and improved habilitation.
Fenner said the staff has felt "very defeated" the past two years, and the state is working to regain their trust, improve the culture and show its appreciation for their good work.
"It think we're headed in the right direction," she said.
Reach JoAnne Young at 473-7228 or jyoung@journalstar.com.