Blue Mass Group

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DPPC faults care plan in group home resident’s death

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(Cross-posted from The COFAR Blog)

A state investigative agency has concluded that a Tyngsborough group home resident died last year as a result of having ingested an  inedible object, and that there was sufficient evidence to conclude that his death was due to a lack of adequate supervision by caregivers.

The 50-year-old man, who had formerly lived at the Fernald Developmental Center, had reportedly ingested a plastic bag.

The March 29, 2012 report by the Disabled Persons Protection Commission, which was obtained by COFAR, concluded, however, that there was insufficient evidence to identify when or how the man had obtained the material he ingested, or whether he was in his group home, day program, or being transported between the two when he ingested it.  The report also appeared to place the blame for the lack of supervision on the fact that the man’s plan of care, also known as an Individual Support Plan or ISP,  had no requirement that he be kept in sight by staff at all times.

The 50-year-old man had lived in the group home for about a year after having been transferred there from the Fernald Center.  According to sources, the man had a history of ingesting foreign objects, a condition known as pica.

The July 6 death of the resident is one of two cases of sudden death involving former developmental center residents, both men in their 50s, which COFAR  first reported about last August.  COFAR also reported about the case of another man who died suddenly of a blood clot in his lung in a Tewksbury group home on July 24, four days after having been transferred there from the Templeton Developmental Center.  An investigation of that death is apparently still ongoing. 

Both Fernald and Templeton are among four developmental centers that have been targeted by the Patrick administration for closure. 

The March 29 DPPC report leaves many questions unanswered about the Tyngsborough group home resident’s death, including whether the man’s ISP was changed in a significant way after he left the Fernald Center, and whether his level of supervision in the group home was less than the level he had received while at Fernald.  There is an indication in the report that the man’s ISP was changed in September 2010, apparently after he moved to the group home, to remove “target (presumably inedible) items”  from mention in the plan.  Much of this discussion, however, is redacted in the report.

The report in general is heavily redacted.  Not only is the man’s name redacted, but even a discussion about what his ISP actually stated is at least partially blacked out.  In addition, what is apparently the word “pica” is redacted throughout the report.
 
The report states, for instance, that as a result of this case, the Department of Developmental Services issued new guidelines for what are apparently “Pica Management Plans” for DDS clients.  However, the word before “Management Plans” is blacked out.  According to the report, the new DDS guidelines recommend development of a specific behavior plan for each person who has what is apparently pica, required training of staff, a description of the supervision required, and other measures. 
 
The DPPC report also stated that as a result of this case, there is reason to believe providers of transportation for group home residents might not be aware of the diagnoses of what are apparently conditions such as pica among all their passengers. The report recommended that DDS consult with “Human Services Transportation” to ensure that “all potentially dangerous behaviors or medical conditions of a passenger is (sic) shared with the contracted and/or subcontracted provider of transportation.” 
 
And the report includes a recommendation that appears to require that ISPs of all DDS clients with pica include additional protections.  The report recommended that:
…the appropriate DDS designee review the above noted additional finding of risk pertaining to (blank) and ISP language and determine what, if any, action should be taken to identify within a person’s ISP those specific items known to be ingested by the person, as a means to minimize or eliminate the risk they pose.
The man died of aspiration pneumonia and a bowel obstruction, according to the City of Lowell Clerk’s Office, where the death certificate is on file.   After swallowing the plastic bag, the man was reportedly taken to Lowell General Hospital, where he underwent surgery.  
 
The DPPC report indicated that the man had a medically related episode either in his day program or his group home more than two weeks prior to his surgery and more than a month prior to his death.  A description of the nature of that incident was redacted in the report. 
 
The report noted only that the man was first admitted to a hospital on June 7, five days after first exhibiting signs that he was not was not feeling well on June 2.  He was discharged from the hospital on June 11, four days after his admission.   He reportedly did not feel well for several days after his discharge, however, and on June 19, he was taken again to the hospital emergency room and had surgery later that evening.  He died a little over two weeks later.
 
Sources said the staff at the Fernald Center had been aware of the man’s pica condition and had watched him closely to prevent him from ingesting objects while he was living there.  Whether that level of supervision was greater than the level the man received at the Tyngsborough group home could not be determined from the DPPC report. 
 
In both of the sudden death incidents about which COFAR reported, the men had been transferred to state-operated group homes operated by Northeast Residential Services, a division of the Department of Developmental Services.  DDS has refused to discuss or provide any information about these deaths, citing confidentiality and privacy regulations.

In a third case about which COFAR recently reported, a 51-year-old resident of a Northeast Residential Services home died on February 7, 2012 after having been sent back to his residence twice by Lowell General Hospital.  That man had formerly lived at the Fernald Center as well.

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Comments

  1. redacted or otherwise. I’m still trying to figure out why the word “pica” would need to be redacted at all–what exactly is private or confidential about the word pica?

    Even though the DPPC report doesn’t say it, I think its clear that this man was not receiving the same level of oversight or care that he got at Fernald. So much for the “equal or better” care that a Federal Court mandated he was legally entitled to as a member of the Ricci Class Action and that DDS was legally obligated to provide him and no doubt promised his family members he would get after leaving Fernald.

    From personal experience I know pica is an extremely difficult behavior to deal with. Obviously the staff at Fernald knew how to deal with it because they were able to keep him safe from himself for 50 years.

    Other than issing a bunch of redacted reports and coming up with behavior plans (which should have been in place before the man moved to the home) no one will be held accountable for this man’s suffering and his death, not NRS or the hospital. It a disgrace, and to put it bluntly because I don’t know any other way to put it, corrective actions plans don’t fix dead! Forgive my bluntness.

    I hope our elected official read this blog once in a while. It could serve as a much needed wake-up call. They were WRONG to force this man out of a home that kept him safe for 50 years because some bureaucrat alleged they could save a few bucks. I guess the bureaucrats were right–they will be saving a few bucks afterall. Completely disgusting but true.

    It is so troubling to me that this man suffered and my heart goes out to the family.

  2. redacted throughout the report, yet references to the man’s tendency to eat inediable objects are left in. The various redactions result in a lot of confusion to the reader, particularly over the question whether the man’s ISP was changed after he left Fernald.

    I did ask DPPC if they could provide clarification of the ISP question in light of what seemed to be arbitrary redactions in the discussion of that issue in the report. I got no clarification in reponse, but the DPPC official did insist that the redactons were not arbitrary. I guess we’ll have to take his word for it.

  3. David,

    A very informative article. Keep up the good work. Redacting “pica” and not “tendency to eat ineditable objects” shows me that the redactor does not understand the special care needs of persons with profound intellectual disabilities (a/k/a profoundly mentally retarded). The redactor looked for a list of key words but did not know the meaning of the key word pica.

    Mav

  4. that the redactor was probably looking for key words. In addition, portions of the discussion in the report about ISPs are redacted, while other portions are left in. It’s impossible for me to judge what the criteria are for these redactions, and the DPPC’s response on this was not very enlightening.

  5. Its difficult to understand that an investigator would not have at least a basic understanding of these terms and conditons and special care requirements. Even more difficult to understand that they would rely on some key words when trying to sort out what really happened here.

    The fact that they did not determine where the system failed is not surprising but its my guess that the failure was such that there was no way to just sweep this under rug (thankfully).

    Keep up the excellent work Dave!!!

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