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Advocacy group cites abuse, neglect at Beatrice center

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By JoANNE YOUNG / Lincoln Journal Star

Wednesday, Dec 05, 2007 - 12:24:22 pm CST

Indifference by state officials continues to result in serious injuries and failures to properly take care of residents at the Beatrice State Development Center, a state advocacy group said Wednesday.

“This must become an urgent priority for state officials,” said Tim Shaw, CEO of Nebraska Advocacy Services. “We say, and it’s time for the public to say, ‘enough.’”

A report by Nebraska Advocacy Services, released Wednesday, says that since 2001 officials have failed to meet accepted standards of care, which has spiraled into an atmosphere of chaos and violence at the center, which houses more than 300 people with developmental disabilities and mental illness.

Persistent staff shortages are a huge problem at the center.

The report showed that for nine months, beginning in January, officials at the center investigated 200 abuse and neglect incidents, including bone fractures in 22 residents. Eighty-six were substantiated, resulting in 209 staff suspensions.

The report, based on reviews of federal surveys of the institution, incident and investigation reports, observations and staff interviews by Nebraska Advocacy Services staff members, identified “a relentless series of … reports of serious harm and ineffectiveness in response to the needs of Beatrice State Development Center residents.”

The center has been cited numerous times by federal regulating agencies in the past several years for deplorable conditions for residents, including staffing shortages, failure to investigate and report allegations of abuse and neglect, inadequate supervision, and failure to implement behavior management plans.

Federal regulations require these types of facilities to protect people in their care from harm and abuse, provide adequate staffing and to reduce dependence on drugs and physical restraints.

Shaw said state officials continue to violate the legal rights of residents and they continue to be at risk of harm.

They don’t have adequate treatment and aren’t learning skills to help them become self sufficient.

“It is not acceptable that these failures have been known and tolerated for years by state officials who have the responsibility to protect (and enable) … the residents at BSDC,” the report said.

The report said the staff shortages — 106 last week — impact the safety and needs of residents. Over 100 direct care staff positions go unfilled each week.

Direct care staff members are working massive amounts of overtime and double shifts, Shaw said. A harmful environment has been created by inadequate numbers of minimally trained staff and a greater number of residents with greater behavioral problems. And without proper treatment, behaviors worsen.

The center “is staffed by many dedicated individuals who are genuinely concerned for the well-being of the residents in their care,” Shaw said. “However the evidence is unequivocal that they are underpaid, undertrained and overworked by state officials.”

The agency has offered recommendations to address the conditions at the center. They include:

-- Create a culture of respect and valuing of all people.

-- Model programs on principles of consistent, positive reinforcement.

-- Do comprehensive evaluations and assessments for all residents.

-- Prepare a timeline to significantly reduce the current population by placing residents into appropriate community settings.

-- Raise pay substantially for direct care and professional staff.

-- Provide adequate behavior management training for staff.

-- Create an oversight committee by the Legislature.

-- Create a section of civil rights enforcement in HHS to protect the rights of residents at all of the state’s residential facilities.

State leaders said last week they hope to reduce the number of people at the state institution in response to continued staffing shortages and federal investigations. They do not plan to close the institution but were unsure how many people might be at the center in future years.

The state intends to: assess clients to determine whether they can be placed in community programs; provide an on-campus pilot program to help clients transition to community care; improve recruitment and retention by overhauling the new employee orientation program, enhance employee recognition award programs and begin a leadership development training institute; and redirect resources through a campus-wide review of programs, moving the thrift shop into the community and assessing the Beatrice State Developmental Center hospital.

Reach JoAnne Young at 473-7228 or jyoung@journalstar.com.


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Rae wrote on December 5, 2007 12:45 pm:
" There is a double standard with the state. If you had these many abuses reported and substantiated in a private sector facility-- adolescent home, home for elderly etc.. their license would be pulled immediately. Why does the state get away with crap like this........two sets of rules?? "

A *very* tired BSDC employee wrote on December 5, 2007 1:41 pm:
" It might be nice if the numbers you cite in the article jive with reality. If there were 200 cases investigated and 86 substantiated, how can there have been 209 suspensions as a result? The answer is that there were 200 initial investigations which *resulted* in 209 suspensions (and then 89 could have been substantiated. This also does *not* mean that 89 clients were beaten up or horribly abused, as some of these substantiated cases are failures by overworked staff to follow correct procedures. Also, please refrain from lumping in *all* cases of broken bones with abuse or neglect allegations. More than a few result from *pure* accidents or medical conditions and *not* because of deliberate abuse or neglect. A bigger problem which some of our good staff have had to face is that when people are being investigated in *any* way, they are *automatically* suspended, even if there is little direct evidence to indicate their involvement. It is the way management has "dealt" with any hint of allegations of possible neglect or abuse, no matter how remote they may be. Staff who have been unfairly accused with no direct evidence get suspended sometimes for weeks at a time. Oh, they are often reinstated once the "investigation" is complete and no evidence is found, but once "suspended", the damage is done. A lot of these dedicated people who get caught up in these "witch hunts" just can't take it when suspended, and they just quit even though they are totally innocent of wrong doing. Whole units have been suspended, forcing even *more* overtime on the already overworked staff. One example of a suspension would be that even if a very minor injury like a simple tiny accidental abrasion is noted, it has to be reported to the manager on duty within 30 minutes and a full two-page report has to be filled out. For an overworked staff with too much going on, that time period might be exceeded, and if it is, guess what? The staff might be suspended! As for an atmosphere of "chaos and violence", I don't see anything in the way of violence where I work (people aren't exactly beating each other up constantly at BSDC), but the atmosphere can be chaotic at times. This is mostly because we are trying to do things without the staffing and planning from management needed to properly carry them out. From the current track record, it appears that the state has been completely unable to deal with the staffing issue, even though it was made *very* clear to those in DHHS after the first Federal Survey exit last year that this should be the number one priority. Things are indeed bad at BSDC, but it would be nice if your writers took just a little more time when writing their articles. Then, the real situation might be better portrayed. "

former employee wrote on December 5, 2007 2:18 pm:
" Hmmm, big suprise. Short of staff. Maybe they should treat their employees better. Anyone worth a darn won't stay there long. I was treated better when I worked at McDonalds in high school. "

employee wrote on December 5, 2007 2:43 pm:
" It amazes me that they can state all the negative but forget to put the quotes of the CMS auditors this last visit when they said that they saw tremendous improvement and the citations and problems they saw were no longer global and just one or two instances. The employees of BSDC are working very hard and a lot of extra hours to provide quality care and improvements. These statements from Nebraska Advocacy are way off base! They are making us sound like evil criminals when in reality we are working very hard to make these individuals' lives better. After reading this and their report, I have no respect for them, they are obviously just trying to make a name for themselves and gain attention by ignoring a lot of facts and the compliments we received in our last visit from CMS. "

Darren wrote on December 5, 2007 3:58 pm:
" Big suprise there are ongoing problems. These circumstances were created by our former govenor trying to get by on the cheap by not properly staffing or paying people to work at BSDC. Cut after cut after cut has whittled down the numbers and qualifications of staff to the point where problems like this were inevitable. Johans didn't care because the victims weren't going to be voting anytime soon. Some of you people are actually considering electing this tool to congress too. Unbelievable. "

Another Former Employee wrote on December 5, 2007 4:55 pm:
" I saw for myself staff who worked non-stop just to keep up with 20 completely dependant individuals, feeding, toileting, and bathing. 2 competent staff worked, the 2 new ones were usually not trained, not able to do lifting, and not interested in working. So the 2 staff who are left do ALL the work. but are paid the same low wages and put up with a constant flow of people who stay a month and quit. Any sane person would quit when under constant scrutiny of making some mistake for which they could be placed on an abuse registery for the rest of their lives, when it could have been an accident or more likely, working TOO many hours with other incompetent staff, I look for the day when those people bond together and SUE the state for these inhuman working conditions. I feel very sorry for those who have no choice but to put up with the ridiculous excuse for management which occurs there. I quit because I couldnt stand being told what to do by people who didnt ever come to work on a unit, or had a clue about training the staff properly. The sooner that place is CLOSED the better. "

two sides.... wrote on December 5, 2007 4:56 pm:
" I first want to say that the job that these people do is very hard. Imagine dealing with these poor people every day, its not easy to care for people with these kinds of disabilities, I am not condoning abuse if that is the case, but a lot of times, the employees endure abuse themselves from the tenant. We dont know the whole story, they may need to make some improvements, because its state funded you know problems are bound to happen. Not enough money, not enough staff, and our government doesnt really care all that much either. "

Employee wrote on December 5, 2007 8:39 pm:
" You want this facility closed? Really. Would you accept a group home for developmentally disabled individuals with violent behaviors next door to you? Most people wouldn't. This group from Nebraska Advocacy neglected to include the huge improvements BSDC has made in the last year. Improvements that were noticed by CMS and Department of Justice. NAS chose only to focus on the negative. There are many very dedicated, very focused employees there, like myself, who are working very hard to improve the lives of the clients who live there and our co-workers. Those of you who don't work at BSDC any more and choose to bad mouth it, didn't belong there in the first place...McDonald's is a better place for you anyway. I am personally very proud of the way people have pulled together to fix the problems and improve things at BSDC. Nebraska Advocacy appears to me to be a group with their own agenda and perhaps a personal vendetta against BSDC. "

Questions? wrote on December 6, 2007 11:02 am:
" Ok if you are reading this then you have some interest in what is going on with the BSDC - I would like to say - job well done to all employees - you are working very hard!!!! I know that the State and the Federal people are not making your life easy - I would also like to ask some the people on this Nebraska Advocacy Services, if they are looking for a job - if they have all the answers and think that the current employees are not doing a good job - then they should apply for one of the many openings??? I know that alot has happened their and I am sure if you look around it is not that different at other State Development Centers - but for some reason the BSDC is always in the spot light???? I would just like to end by saying - you are all doing a great job!!!!!! (BSDC current employees) Keep it up!!!! "