Death at developmental disability center prompts move of medically fragile residents

From The AP in Nebraska:

LINCOLN, Neb. -- A death last month at the Beatrice center for the developmentally disabled may have involved medical negligence and has led Nebraska's chief medical officer to order all "medically fragile" residents removed from the troubled center.

The Beatrice State Developmental Center is home to about 240 people, most of whom are mentally retarded, and it has been harshly criticized in reports that have jeopardized $29 million in annual federal funding.

A state investigative report released to The Associated Press shows a messy, confused response to a resident's seizure on Jan. 15 at the center.

According to the report:

-- There was a 15-minute wait before medical help was sought.

-- Staffers weren't aware of the patient's medical history, were not all trained to handle seizures -- even though 17 of the 18 residents in the unit had a history of them -- and they were not all aware of the facility's procedures on handling an emergency.

-- The nurse who finally arrived broke off a syringe needle in one of the patient's legs when trying to provide medicine, then she left to get more medicine. After properly administering it, she reportedly left the other staffers with no instructions on how to care for the person.

-- The seizure continued, lasting a total of 90 minutes including the time before the nurse came.

-- The resident died a day later.

Nothing in the report says the handling of the patient contributed to her death.

Gage County Attorney Randy Ritnour, who is investigating the death, identified the patient as 18-year-old Olivia Manes. He is awaiting autopsy results.

The state's chief medical officer said on Monday the state was examining whether the case was marked by "medical negligence."

"I do believe there is a potential risk of death of serious physical harm to residents who are medically fragile," said the medical officer, Dr. Joann Schaefer, as she announced her order to move the 35-40 residents.

Schaefer told Gov. Dave Heineman on Friday evening that she would bar the center from handling medically fragile people.

She signed the order late Saturday night, after she and Heineman spent part of the day trying to find hospitals that would accept the people.

"There's no question, this is deeply troubling and very disappointing," said Heineman, who deflected questions about what the order might mean for the future of the center.

The order requires the residents who meet the medical criteria to be moved to a Lincoln or Omaha hospital by 5 p.m. Friday. The residents could be in hospitals for several months before possibly moving into community-based programs or other settings.

A hearing scheduled for next week will help determine whether there will be a permanent prohibition on the center holding medically fragile people, defined as people with developmental disabilities and additional complications such as seizure disorders, diabetes or other medical conditions requiring intensive care.

The state has not ruled out shutting down the center if it loses its appeal of the federal decision to yank both the annual support and the center's certification.

While state officials point to two deaths -- one in March 2008 and one this past Jan. 16 -- for the reason for the order, at least two other deaths that occurred in January are being investigated.

An advocacy group that gets federal dollars to protect developmentally disabled people is investigating the deaths and calls them "arguably avoidable."

"The state makes promise, after promise, after promise and they are either not kept or are broken, and residents continue to be the ones who suffer," said Tim Shaw, executive director of Nebraska Advocacy Services.

Four residents of the center died in January. There are no criminal allegations in any of the deaths, including Manes', according to Ritnour.

Two are not being investigated and one -- the Jan. 24 death of 29-year-old Kyle Kurtz from pneumonia -- is slated for "further review," he said.

But Ritnour said he expects some type of review of all the cases will be done in consultation with Attorney General Jon Bruning's Office.

Ritnour said he doesn't expect to look into whether there was medical negligence in the cases because that act is covered by civil law, not criminal law that is the purview of his office.

The other two residents who died are 55-year-old Craig Watkins, who died Jan. 4 from pneumonia, and 79-year-old Donald France, who died of cardio-respiratory arrest on Jan. 19, according to Ritnour.

Shaw said the earlier deaths should have prompted an earlier issue of the order that Schaefer gave on Monday. The relatively young ages of both Kurtz and Watkins, along with their cause of death -- pneumonia -- raises the issue of whether their deaths could have been prevented, he said.

But Schaefer said the state's investigations of the other deaths had "multiple conclusions." She wouldn't describe them, saying only that the investigations "have been completed and they have been addressed appropriately."

Following the investigations, "we found the facility was meeting requirements" to ensure residents were receiving adequate care, she said.

Pressed to say whether there was medical negligence in the other cases, she said: "I'm not the decider of medical negligence. I'm the decider of whether or not the facility can put in the proper procedures and policies" to properly care for residents.

The number of deaths wasn't part of her decision to issue the order, she said. "But how each one has been handled, some appropriately, some not, they have given us the reassurances that we needed in the past that is no longer there."

Heineman called on changes to be made quickly at the center, but he didn't outline specific steps, other than removing the medically fragile residents.

The CEO of the center recently took another position at the facility, and the state is conducting a nationwide search for another CEO.

Shaw said that if improvements aren't made at the center, "litigation is certainly an option" for the group, which has filed a wrongful-death lawsuit against BSDC in the past.

A U.S. Justice Department investigation uncovered about 200 cases of alleged neglect and abuse at the hospital from late 2006 to late 2007. In June, the state agreed to a settlement with the Justice Department to avoid prosecution and financial penalties for the hospital's problems.

At the time, the Justice Department said state officials had demonstrated a commitment to address the needs of the center's residents.