Article: Group home death related to lack of medical records
Lack of medical records can be deadly if a child has a condition that care-givers need to be aware of, such as allergies.
The case I am familiar with had this problem, also. The teenager had a long history of health care, and it appeared that treatment after being taken into foster care was totally ignorant of his condition, history and needs.
http://www.timesdispatch.com/servlet/Sa ... 7833815664
(I am copying this, because it is recent and free, whereas archived articles cost money.
Group home faulted in autistic boy's death
He choked on his own vomit while being held; CEO disputes the report
BY MICHAEL MARTZ
TIMES-DISPATCH STAFF WRITER Feb 2, 2006
RELATED: Police Beat
On Dec. 23, 2004, a 13-year-old boy choked to death on his own vomit while being held face down on the floor of a Winchester group home by as many as six members of the staff paid to care for him.
The boy, who was autistic and mentally retarded, had arrived the day before at the group home operated at 920 Frederick Ave. by Grafton School Inc., one of Virginia's biggest providers of care for youths with behavioral problems and disabilities. He was placed in the Grafton facility, about five hours from his home in Southwest Virginia, because of aggressive behavior that had caused him to be committed to two state institutions earlier that year.
A state investigation of the death has concluded that the group home's staff was uninformed and ill-prepared to handle the boy, who was 6 feet tall, weighed 241 pounds and had limited ability to express himself. The investigation, completed last month, also found that the staff used an inappropriate form of restraint on the boy and did not relent until he began to turn blue.
"There is evidence to support that staff continued to hold [the boy] in a lying-down restraint when he began vomiting," the report states in respect to one of 12 alleged violations of Virginia interdepartmental regulations for group homes. "Vomiting is a sign of distress. Staff ignored vomiting as a sign of distress."
The home's staff also failed to respond quickly enough to the boy's dis- tress with mouth-to-mouth resuscitation, partly because the necessary safety equipment couldn't be found, the report states.
Grafton, a nonprofit organization that has operated in Virginia since 1958, was to deliver a required plan to state officials today to correct the problems identified by the investigation.
However, Grafton Chief Executive Officer James G. Gaynor II took strong exception to the state report. "We're certainly very much in disagreement with many of the findings," he said Tuesday.
Group homes are a hot topic in this year's General Assembly session because of concerns about the care they provide, as well as their relationships with their surrounding communities. Most of the care is publicly funded by state and local governments, or the federal Medicaid program.
The homes are licensed by different agencies responsible for children and adolescents, using a common set of interdepartmental regulations. In Grafton's case, the Virginia Department of Education is the state agency that licensed the home and led the investigation.
However, the education department was assisted by the Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services, and its Office of Human Rights.
The Winchester Department of Social Services also participated in the investigation but issued a separate report based on child protective service regulations. The report found that the group home was not guilty of abuse and neglect under those rules in the boy's death.
In addition to violations of interdepartmental regulations for group homes, the state investigation cites Grafton for eight alleged violations of state mental-health standards and eight alleged violations of human-rights standards for people in therapeutic programs. The most serious was the alleged lack of information about the boy's behavior and medical condition when he was admitted to the home.
"The information collected at the point of admission is significantly inadequate, especially medical information," the mental health department states.
Virginia already has issued Grafton a six-month provisional license for the group home at 920 Frederick Ave., according to the education department. The provisional license is a temporary measure to allow the owner to make changes in the way it operates the home and cares for its residents to bring it into compliance with state regulations.
Grafton, based in Winchester, operates 23 group homes across Virginia, including 12 in the Richmond area, and a large residential facility in Berryville. Each home is licensed separately, so the investigation's findings apply only to the home in which the boy died.
The nonprofit organization has been a linchpin for care of people with behavioral problems related to developmental disabilities, especially autism. The Virginia Autism Resource Center, with offices in Midlothian and Winchester, is a division of Grafton.
Mount Rogers Community Services Board, the Marion-based agency that referred the boy to Grafton, would not comment on the case or the report.
However, Executive Director Lisa Moore said Grafton is an important option for communities that cannot find the special care these children need closer to their homes. "Grafton is a resource that we use once we've explored everything else," she said.
Moore added that her agency also tries to find help for children outside of state institutions. "I don't think being in an institution for a long time is a good alternative either," she said.
The boy, whose name was blacked out of a report provided to The Times-Dispatch by the Department of Education under the Freedom of Information Act, had been admitted to the Southwestern Virginia Training Center in Hillsville twice in 2004 to give his family respite from behavior that had become increasingly aggressive at home and school, the report said.
In November 2004, he was admitted to the Southwestern Mental Health Institute in Marion, where he remained until he was admitted to Grafton on Dec. 22, 2004, the day before he died. The state investigation found that the group home had not collected information about his stay at the training center and partial information from the mental hospital.
"This is particularly troublesome," the report states, "when it is understood, that prior to admission to Grafton, the student spent considerable time at these two facilities."
Contact staff writer Michael Martz at
[email protected] or (804) 649-6964.