Records show lapses, gaps at state-run sites
Swallowing instances among findings
A choking death at a southeast Arkansas center for people with disabilities followed three other incidents in which residents at state-run centers swallowed batteries, marker caps and other household objects, records show.
The four events spanning roughly 15 months involved clients with known histories of trying to eat objects or — in the case of the man who died — food that wasn’t part of his prescribed pureed diet.
In July, the 38-year-old man, with a moderate intellectual disability and a condition that causes trouble swallowing, was “left unsupervised” at the Southeast Arkansas Human Development Center in Warren, an inspector wrote in a report. The man entered an office, took a piece of cake he found there and choked on it.
On three other occasions since 2019, clients at the Warren site and a sister facility in Booneville swallowed objects that could have harmed them, internal documents obtained under the state’s public-records law reveal. One such incident required surgery.
The inspection reports and other Department of Human Services records
show gaps in supervision at human development centers that put vulnerable clients at risk, especially individuals diagnosed with pica, the medical term for the urge to eat non-food items.
In an email, Division of Developmental Disabilities Services Director Melissa Stone said teams of clinicians work to determine appropriate levels of supervision for clients, including those with pica. Staff members involved in the incidents referred to in this article “did not meet the expectations we have at our centers,” she wrote.
In the case of the man who died, “a staff person failed to follow established safety guidelines which allowed the client to access the food that was not on his approved plan,” she wrote. “That staff person was identified, placed on leave during the investigation, and terminated due to her failure.”
While he agreed that staff members involved in the incidents didn’t do their jobs, Disability Rights Arkansas Executive Director Tom Masseau said the events raise “a lot of questions” about supervision and training within the facilities, especially for workers caring for clients with complex behavioral issues.
“What is the state doing to prevent this?” asked Masseau, whose group is a federally mandated watchdog. “Instead of forming committees and blam[ing] it on the employees … let’s look at this systemically. How can we improve the quality of care that residents are receiving?”
Roughly 865 people live at five state-run sites, called human development centers, for people with disabilities and other health issues. Some residents have trouble communicating or can’t walk. Some are visually impaired, blind or deaf, according to annual reports submitted to federal regulators.
An Arkansas Democrat-Gazette review of records this fall has shed light on issues within the facilities, including practices surrounding the use of physical restraints, which outside experts said are problematic, and failures to follow rules meant to ward off covid-19 infections.
Records show that the 38-year-old man who choked was hospitalized and connected to a ventilator. He died at a Little Rock hospital July 6, a coroner’s report shows.
In response to a description of the incidents and the death, one expert called them “terrible — but not terribly uncommon” in large institutional settings for people with disabilities. Decades of research, she said, show that such facilities struggle with turnover, staffing shortages, inconsistent supervision and piecemeal clinical care.
“We’ve closed most of these places across the country — most states don’t have them,” said Amy Hewitt, director of the Institute on Community Integration at the University of Minnesota. Even for people with challenging behavior such as pica, “it’s just not true that they are better off in a big institutional place.”
Pica isn’t “well-understood” as a behavior, cautioned Dr. Stephen Ruedrich, a University Hospitals Cleveland Medical Center psychiatrist who has treated people with disabilities and mental illness. It can have physical origins, such as an iron deficiency; psychological triggers; or be a way for people with developmental delays to explore the environment.
He said clinicians “struggle with it in the field” and that it tends to be more common among people who live in residential-care settings or institutions.
Nearly a year before the 38-year-old man died, a staff member at the Warren site was changing the diaper of a different man, who had a profound intellectual disability, when the employee found three latex gloves, a piece of paper towel and blood in the client’s bowel movement, an inspector wrote in a report.
Staff members told an inspector that they didn’t know where or when the man obtained the gloves. Video later showed the man unlocking the patio door of the facility and leaving the unit for six minutes without the staff realizing he was gone, a report said.
The facility failed to ensure that the client wasn’t subject to neglect, one of the conditions of its participation in Medicare and Medicaid Programs, regulators said.
‘NO PULSE’
According to the 38-yearold man’s obituary, he loved his nieces and nephews, enjoyed listening to Christian music and liked to accompany his mother on a paper route. A coroner’s report said he had Down syndrome, a genetic condition that can cause developmental and physical differences.
The newspaper isn’t naming the man because a member of his immediate family did not return voicemail messages or an email message requesting comment.
A July 16 report details the circumstances that led to the man’s death, in which he gained access to an unlocked office and obtained the cake, an inspector wrote.
Staff members described a chaotic scene to an inspector, in which they tried to perform the Heimlich maneuver and attempted to clear his airway using their fingers. A nurse’s note excerpted in the report described the man, his face blue, lying on the floor of a bedroom.
“Attempted to locate a pulse. No pulse located,” the nurse wrote.
An ambulance transported the man to a nearby hospital.
Staff members later told regulators that the man previously tried to access food in the staff area, according to interviews quoted in a report.
“Was there a time before when [this client] got into [the] office and got a cookie?” an inspector asked a supervisor, who said she had been working in the house for one month.
“Yes,” the employee said. Inspectors also noted unlocked storage closets that held chemicals such as heavy starch and a cleaning solution, which they said imperiled three clients on the center’s pica list. Failure to lock the office and the closet doors earned the facility an “immediate jeopardy” citation.
The designation, or “tag,” is regulators’ most serious notation. It’s used for incidents that caused or could have caused injury or death to long-term-care residents, and was applied in all four incidents this article describes.
A conclusion statement from an Aug. 27 meeting of a state committee that reviews deaths in the human development centers said the man was transferred from a smaller hospital to the intensive-care unit at Baptist Health Medical Center in Little Rock.
Days later, he was “determined per tests to be without brain function or activity” and was removed from a ventilator, the statement said. Administrators made changes to employee break schedules and other practices to ensure that all doors were locked at the center, and the committee determined that the “standard of care” was met in the death.
Asked how a situation could have caused “immediate jeopardy” but also have met the “standard of care,” Stone wrote that the employee who failed to keep the door locked didn’t meet standards. The committee found that the staff responded to the emergency appropriately, she said.
“The issue in this case was not that the client was unsupervised, but rather that the staff member did not follow requirements for locking the door,” she wrote.
‘SURGICALLY REMOVED’
Records show that a known history of trying to swallow things — which applies to about 86 people across the five centers, Stone said — did not always ensure clients’ safety.
One such client was at the Booneville Human Development Center. This client had a mild intellectual disability, bipolar disorder and pica and was under 1:1 supervision, in which one staff member closely watches one client.
In April 2019, the client had a conflict with another resident and then asked if she could use a Wii video-game console remote.
When a staff member provided the device, the client swallowed two AA batteries that had powered it, a report said.
“Since [the client] had just been upset do you think she should have had [the remote]?” an inspector later asked a program coordinator at the facility, according to the report.
“No, I wouldn’t think she should have it,” the coordinator replied.
The batteries were surgically removed.
Within six months, inspectors filed another report on the same client, who was taken for additional X-rays after swallowing two 2-inch marker caps. She had attempted to swallow a third.
The state agency terminated employees over the incidents and retrained the staff, Stone wrote in an email.
The client in question is barred from possessing small objects and must move from place to place with her arms crossed, hands folded or while holding onto a safe object.
A pica diagnosis alone doesn’t automatically result in 1:1 supervision, Stone explained. The majority of Arkansas’ human development center residents — about 650 people — are under “general” supervision, in which they’re free to move about the campus without a staff member.
“The goal, even within a human development center as a self-contained facility, is to give clients a high quality of life in the least restrictive setting while ensuring their health and safety,” Stone wrote.
Masseau, the advocate, said his organization has documented similar episodes in other facilities around the state, including at psychiatric residential treatment facilities for youths.
Many of those facilities are privately run, but are overseen by the same parent agency as the human development centers.
Masseau agreed with expert opinions that these types of episodes were more likely to happen in institutional settings, adding that when a single supervisor is trying to manage care for 15 or more clients, “they lose track of who needs what,” he said.
People diagnosed with pica can be helped by medication, behavioral interventions and observant staff members, said Ruedrich, the Ohio-based psychiatrist.
“The best approaches really are managing the environment so that people just don’t have access to things that can be swallowed but shouldn’t be swallowed,” he added.