State hasn't reviewed deaths of disabled people at developmental center in Nebraska

From The AP. In the picture, Brady Kruse, a former resident of the Beatrice State Developmental Center, died last November, nine months after he was moved from the center.

LINCOLN, Neb. — Medical reviews that could have shed light on potential dangers of moving developmentally disabled people from a state institution haven’t been conducted as state officials said they would. And a committee has been slow to review the deaths of some of those patients as required by the federal government.

All told, state officials — including Nebraska’s chief medical officer — say they haven’t learned anything from what death rates, experts and parents of developmentally disabled people who have died indicate was a disastrous decision to force 47 people from the Beatrice State Developmental Center 1½ years ago.

Death rates calculated and reviewed by the Associated Press also show that previous moves may have exacted a toll on former residents of the center, most with severe mental retardation.

“I don’t know if there’s anything I’ve learned from that particularly,” Dr. Joann Schaefer, the state’s chief medical officer, said recently of moving 47 people from the center in 2009. Schaefer ordered the move following a couple of deaths at the troubled center that she said showed the facility had become too dangerous for medically fragile residents.

The lack of lessons learned exists at the same time officials continue to urge people with severe mental retardation to leave the center.

“Some of what happened to them should never happen to anyone, and we should learn from that,” advocate Margaret Huss said when told the state hasn’t done reviews of the cases and has been slow to do others required by an agreement with the federal government. Huss is on the board of the Mental Retardation Association of Nebraska and warned in a letter to state officials shortly after the 47 medically fragile residents were moved in February 2009 that the sudden move could have “catastrophic results.”

“I think the numbers speak for themselves. ... There was little planning, and decisions made by people with little or no experience with these people,” said Huss, whose brother lives at the Beatrice center.

Under an agreement with the federal government, the state had to form a special committee to help identify and promptly resolve preventable causes of death by reviewing deaths of Beatrice clients, including the medically fragile removed from the center in early 2009.

But to date, the committee has reviewed just three of the 12 deaths of medically fragile former residents who were moved and less a dozen other deaths of center clients since 2007. An expert appointed to review progress at the center said it took nearly a year after some deaths before reports were finalized.

“Such lapses in time have the potential to render the information useless,” said Maria Laurence, the expert appointed to monitor the state’s progress in meeting terms of a 2008 settlement with the U.S. Department of Justice over poor conditions at the center, in a June report.

Jodi Fenner, the state’s developmental disabilities director, said a second committee of medical professionals has been formed to review deaths, which could increase its work production.

Also incomplete is a review that Schaefer said a year ago would be done by two nurses with no connection to the Beatrice center.

Schaefer said at the time that part of the job of the nurses would be to review how the conditions of the medically fragile she forced to leave the center were managed after they left. The intent of the review, she said, was not to determine whether the move affected their health conditions.

Schaefer said she decided later not to have the reviews done because they would have been redundant. She said she was getting sufficient information from state staff.