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

The Denver Post - - FRONT PAGE - By Christo­pher N. Osher

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.

RJ San­gosti, The Den­ver Post

The Pue­blo Re­gional Cen­ter is one of three fa­cil­i­ties in Colorado that are home to adults with de­vel­op­men­tal, phys­i­cal and in­tel­lec­tual dis­abil­i­ties.

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