One person was convicted
Between 2012 and early 2016, incidents at the Pueblo Regional Center were reported internally at a rate of about 150 each month At least 12 cases were investigated by the Pueblo County Sheriff’s Once 2 people were charged Cases involving disabled victims
Residents at a state-run center in Pueblo for the severely intellectually disabled were subjected to sexual assaults and ongoing physical abuse and neglect from 2012 to early 2016. Incidents ranging from patient discomfort to more severe allegations of abuse were reported at a rate of about 150 each month to the center’s staff during that time, according to federal records.
In the end, just two staff members were charged criminally and only one was convicted. That was for the petty offense of making too much noise. At least 12 cases were investigated by the Pueblo County Sheriff ’s Office. Eight employees were fired.
The reasons that so few faced criminal sanctions range from difficulty prosecuting cases in which the victims are mute and incapacitated to a reluctance on the part of co-workers to testify against one another. But a review by The Denver Post also found significant miscues in how police work initially was handled.
State officials have conceded that protocols for protecting the disabled were not followed at the center, inhibiting investigations and raising concerns about a system that is supposed to provide care for as many as 12,000 intellectually and developmentally disabled people throughout the state.
Three residents at the center died under questionable circumstances, a federal report this year found. Two died of complications from bowel obstructions and a third was not given life-saving care after a collapse because a staffer thought there was a do-not-resuscitate order. The federal review concluded abuse at the Pueblo Regional Center was so severe that new residents should be barred from the facility and the state should have to repay millions in Medicaid funding.
“Sadly, there is some dehumanization that goes on with people with significant disabilities, especially when you are dealing with a population that is non-verbal or with cognitive impairment,” said Julie Reiskin, executive director of Colorado Cross-Disability Coalition. “Another big problem is the fox is watching the hen house. Nobody wants to report on their buddies, and there hasn’t been a clear line of accountability.”
Fired but not charged
Those who escaped prosecution include a caregiver who was accused three times of sexually assaulting residents.
“Your lips are soft as a baby’s butt,” he allegedly whispered inches away from one resident in May 2014, telling her he wanted to touch her genitals, according to allegations contained in one investigative report.
He had been accused about a year earlier of coercing another resident into touching his genitals in exchange for a soda. In a 2009 case, a resident alleged he had touched her breasts, buttocks and crotch on three separate occasions.
Although the state eventually fired him, the district attorney in Pueblo, Jeff Chostner, decided against pursuing a criminal case, rejecting a recommendation for the filing of criminal charges from the Pueblo County Sheriff’s Office. Sheriff’s investigators had failed to take into evidence video from a nearby security camera that may have captured one of the alleged assaults.
A Pueblo County judge dismissed the other criminal case last week, over the objections of a prosecutor. A co-worker did not answer a subpoena to testify against Sharifa Al-Motairey, who was charged with two counts of caretaker neglect. Al-Motairey was accused of squirting a sleeping resident in the face with a water bottle and of locking another resident outside in the cold for two hours.
“These are difficult cases,” said Kyle McCarthy, a deputy district attorney in Pueblo, who prosecuted the two criminal cases. “They are difficult to prove, particularly when there isn’t a physical injury that you can present to a jury. The two individuals in this last case aren’t competent to testify. They are low functioning and non-verbal. You are relying on an independent witness, and she clearly seemed to not want to cooperate when push came to shove.”
The Post reviewed Pueblo County Sheriff’s Office documents to see how the criminal justice system responded to allega- tions at the center, obtaining 11 reports after filing open-records requests. Federal officials cited 12 sheriff ’s reports in their audit of the facility.
Prosecutors declined to pursue criminal charges against six individuals despite recommendations from sheriff’s investigators that they do so, records show. Chostner did not respond to requests for comment.
No charges were filed against one staffer who left the inner thigh of one “severely mentally retarded” resident blistered with second- and third-degree burns. The staffer had tried to use a hair dryer to warm up the resident — who had the mental capacity of a 1-year-old and was blind in one eye and unable to speak — after her body temperature dipped dangerously low. Nor were criminal charges filed against caregivers who circulated on social media photos of non-verbal patients who had words such as “die” and “kill” scratched into their bodies.
The only conviction resulting from the abuse allegations was a guilty plea to making an “unreasonable noise in a public place or near a private residence.”
A center employee reported in March 2015 that she had seen health-care tech Melissa Lorenzo smother a resident with a blanket, hit his shoulder and kick him in the leg. The employee also said she had seen Lorenzo use a broom to push a resident outside and threaten to use a pencil to slit the throat of another resident. The center’s administrator and a sheriff’s detective concluded the coworker’s account wasn’t sufficient for criminal charges.
Nearly a month later, when officials with the Colorado Department of Human Services became concerned a culture of abuse had developed at the center, another sheriff ’s investigator looked into the case. Lorenzo was then charged with two counts of caretaker neglect.
McCarthy said the delay did not hamper his prosecution. But Division Chief David Lucero, who is in charge of investigations for the Pueblo sheriff, said time is crucial when victims are unable to communicate well.
“Trying to get information is almost impossible if you are getting an allegation late,” Lucero said.
Now Lorenzo, who pleaded guilty to the petty offense in a deferred sentence arrangement, appears poised to get her job back after filing an appeal with the state personnel board.
An administrative law judge ruled Lorenzo’s firing should be reversed because her firing was “arbitrary and capricious,” and that Lorenzo likely pleaded guilty because she was unable to afford the attorney fees to go to trial.
The judge, Susan Tyburski, excoriated the state for a slipshod approach to collecting evidence for personnel actions by relying on how law enforcement handled the case. Tyburski said in her ruling that the human services department had “neglected or refused to use reasonable diligence and care to procure such evidence as it is by law authorized to consider in exercising the discretion vested in it.”
Reiskin, of the Colorado CrossDisability Coalition, wants the state to create an inspector general position to review the care of the disabled. She said the disabled are so vulnerable they cannot advocate for themselves, so the state must improve its system for documenting allegations of abuse.
“Within the system in general, there has been a problem with quality investigations,” she said. “Often, it’s just focused on whether the documentation has been turned in and not a deeper look at why does this person have a bruise or why did this person go to a hospital or why does this person react when certain staff people are in the room. Those quality investigations take more time and more money.”
Those who worked at the center in Pueblo said the lack of extensive criminal convictions shows they were unjustly maligned. They say the state exhibited bias against them.
“We’re easy scapegoats,” said Jason Faber, a former nursing director of the center who battled allegations about the quality of care. “I got bullied out of there by the state.”
Allegations pile up
Officials with three state agencies — human services and those in charge of health and Medicaid spending — realized in 2015 that they lacked proper protections for residents after they discovered abuse allegations had been piling up for years without a sufficient response, according to personnel appeals obtained through open-records requests and the federal audit. Documents show the state suspected a sheriff’s investigator was covering up for accused staff members and was biased against residents because the Pueblo community “covers for each other.”
A state quality assurance investigator encouraged installation of hidden video cameras in the regional centers as a way to protect residents.
“As with many instances of abuse against vulnerable populations, those being abused cannot corroborate the abuse,” Anthony Gherardini, a deputy director and emergency manager in the human services department, wrote in a 2015 e-mail to another official.
“Investigations involving these populations and behaviors are unconventional and rarely can be decided based on traditional interviews and after-the-fact information,” said Gherardini, a former Lakewood police detective, adding that cameras could help. “Due to the fact that the potential victims cannot speak out on their own behalf, additional evidence must be gathered to prove cases of abuse.”
Former center director Valita Speedie wrote in a personnel document that strained staff relations in the Pueblo center several years ago led to vicious retaliatory acts, including the “hanging of a dead dog from the Administration Building’s flagpole.”
In March 2015, state officials became so concerned that they strip-searched 62 residents to look for signs of abuse — a move that prompted a backlash from legislators when some residents and their guardians said the actions were taken without consent. The state health department later determined the body checks were a violation of residents’ rights. Police reports show the strip searches found one semi-verbal resident wearing two urinesoaked diapers with bruises on her right foot and buttocks. Another “profoundly retarded” resident, who was blind and epileptic, had a bump on the side of her head and bald patches in her hair. No criminal charges were filed in either of those cases.
Speedie resigned shortly after, under pressure from state officials.
An on-site review by federal officials in April found that residents remain at risk, with staffing shortages, improper use of restraints and poor monitoring of psychotropic drug use.
The federal review found the regional center failed to forward abuse allegations to Colorado BlueSky, its oversight community centered board. BlueSky then failed to alert the Colorado Department of Health Care Policy and Financing, the state’s fiscal agent, which is required to investigate incidents to ensure the safety of residents. The center did document some of the allegations for the health department, which is in charge of licensing the center. Yet, that agency usually rubberstamped those reports and “often found that the facility acted appropriately by reporting the occurrence,” even when deficiencies should have been cited, the audit found.
Gov. John Hickenlooper has said an independent monitor will make sure the state is fixing the troubled center. State Medicaid officials say they are coming up with a streamlined approach for identifying and preventing mistreatment of those living in the center and similar facilities. The state won’t finish overhauling systems that alert officials of occurrences and critical incidents at centers for individuals with developmental disabilities until September, according to a corrective plan the state filed with federal officials. In the interim, the state has beefed up training and monitoring, and pledged to fix staffing issues at the center.
“The current incident reporting process is effective at ensuring the health, safety and welfare of our clients,” Marc Williams, spokesman for the state’s Medicaid department, wrote in an emailed statement. “The creation of the long-term system is still in development and funding for which is in the Governor’s budget request pending the legislature’s approval.”
Help came too late
Lost in the process were residents such as Julie McCoon, who died at the age of 52 in November 2014. McCoon struggled from birth with Cornelia de Lange syndrome, a developmental disorder that eventually left her schizophrenic and prompted her family to send her to the center. Health complications prompted the removal of her colon, and she had to wear a colostomy bag. She was lying in her vomit and feces throughout most of the day on Nov. 15, 2014, sheriff’s records show. A staffer who cleaned her reported the center’s registered nurse rejected his pleas for an ambulance, telling him “the flu is not an emergency status.”
McCoon, who went by “Julie Bug,” threw up again later that day. The nurse eventually relented after the staffer grew alarmed. When it became apparent McCoon was too unsteady to stand, the nurse called an ambulance. McCoon’s temperature rose to 102 degrees after she was admitted to the hospital, where her stomach was pumped. She died the next day. The hospital determined her bowel had been obstructed.
The sheriff ’s office did not refer the case to prosecutors.
The federal audit noted that two of the center’s residents had died less than a year apart due to bowel obstructions. “Each client had a standing order from the (Pueblo Regional Center) nurse to be provided with ‘melted butter and prune juice’ for constipation, rather than a physician’s order for the use of more effective constipation medications,” that audit found.
“You wonder how in the heck can anybody get that bad,” said McCoon’s sister, Gwen Janco. “You would think there would be signs of something occurring before that came on.”
The body was cremated. Janco said a small trust fund set up for McCoon after a car accident had run out, meaning no money was available for burial.
The Pueblo Regional Center is one of three facilities in Colorado that are home to adults with developmental, physical and intellectual disabilities.