State home for retarded censured by U.S. 'Serious deficiencies' at Shore facility must be corrected, state told

August 28, 1998|By Diana K. Sugg | Diana K. Sugg,SUN STAFF

Citing harmful conditions that have led to serious illnesses and one death, federal investigators have found that a state-run center for the mentally retarded provides poor health care and little rehabilitation.

The U.S. Department of Justice ordered the state to correct the deficiencies at the Holly Center, a 23-year-old facility in Salisbury.

"Notwithstanding what seemed to be commitment to the residents and good intentions on the part of administrators and staff, we found a number of serious deficiencies at Holly Center," said Lynne A. Battaglia, the U.S. attorney for Maryland.

State health officials, who received the federal report Wednesday night and released it yesterday, said they had been aware of inadequacies dating back to January 1997 through their own evaluations. Dr. Martin P. Wasserman, state health secretary, said steps already have been taken to correct the problems, including reorganizing the center, hiring a new quality assurance director and offering more training in recognizing acute illness.

"We're working to resolve each and every specific recommendation," Wasserman said. "We've brought in experts from other states. We believe this is going to be resolved amicably."

The Eastern Shore facility, one of four state institutions for the developmentally disabled, houses about 170 people, including 17 children and adolescents under age 22. In recent years, as many healthy and higher-functioning residents have moved out to the community, the center's remaining population has become even more vulnerable.

Almost 60 percent of the population is considered non-ambulatory, and about half are on psychotropic medications. Half the residents are considered medically fragile, and the rest have behavioral problems.

There were eight deaths at the center in the past 18 months, only one of which Wasserman identified as being linked to the inadequate conditions. In that case, a 54-year-old severely retarded man didn't receive treatment for a problem with his catheter until hours after he became acutely ill, the federal investigators said.

He died soon after of a heart attack at Peninsula Regional Hospital.

The report cited chronic deficiencies in dealing with feeding, choking and aspiration incidents, which are common at the Holly Center. But, according to the investigators, neither the center's medical director nor the staff physician has any special training or continuing education to deal with those problems.

Although the center has begun to take some action, the investigators said that unsafe feeding practices were still prevalent, and meals were rushed.

Staffers were not trained to deal with choking incidents and didn't record them properly, the report said.

In one incident observed by the investigators, a resident began coughing and turning red, but the staff didn't respond. When asked by the investigator, a nurse responded, "He is always like this." The resident coughed again, struggling for breath. At that point, the nurse finally adjusted the man's position, relieving the problem.

The report pointed out other problems, including poorly designed wheelchairs that cause skin injuries, rough handling of patients while being moved, and inadequate care by the center's infirmary.

Insufficient staff supervision was also an issue. According to the report, residents have been found with lacerations, fractures and human bites without any staff knowledge of how the injury occurred.

The investigators also complained that the state failed to move 17 children to group homes or other community placements, as required by law.

According to Wasserman, seven of those children have been moved since the report was written, and several others will follow them.

Wasserman said that some of the corrections at Holly Center will take time, like replacing staff who took early retirement last year, and re-organizing the center. The facility already has improved procedures for choking incidents, he said. Custom-designed wheelchairs and other equipment have replaced the ill-fitting chairs criticized by the investigators, he added.

It was unclear last night what sparked the investigation, which began last summer. But Carol Benner, head of the state Department of Health and Mental Hygiene's licensing and certification division, said the Holly Center was threatened with losing its Medicaid contracts -- most of its income -- in early 1997 if it didn't make corrections.

Advocates say they plan to monitor the situation at the Eastern Shore facility.

"We've been assured for some time that Holly Center is a model institution. It's clean. It looks good when you go down and visit," said Cristy Marchand, executive director of the ARC, a statewide advocacy group for the developmentally disabled. "But this is far worse than we had understood."

Pub Date: 8/28/98

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