[Cross-posted from The COFAR Blog]
The state Disabled Persons Protection Commission has substantiated charges of abuse and neglect against a staff worker in a Bedford group home in which Paul Stanizzi, an intellectually disabled man, was seriously injured last August.
Stanizzi was at least partially paralyzed in the incident in the residence, which is operated by The Edinburg Center, Inc., a corporate provider to the Department of Developmental Services. According to a DPPC report on the incident, Stanizzi was found lying on his back in his room by the staff worker on the morning of August 27. The staff worker, who had been on the overnight shift, told investigators he had heard noises in Stanizzi’s room during the night, but never investigated them and then fell asleep for several hours during his shift.
After finding Stanizzi unresponsive on the floor at 6:30 in the morning, the staff worker admitted he lifted Stanizzi up, in violation of his First Aid training, and put him in his bed. He then waited approximately 25 minutes prior to calling 911.
Stanizzi, who is non-verbal, was taken to Lahey Clinic in Burlington, which was planning to discharge him, according to the DPPC report. But the hospital then admitted him for immediate surgery when it became apparent that Stanizzi had a spinal injury. No group home staff accompanied Stanizzi to the hospital, according to the report.
The name of the group home staff worker is redacted in the DPPC report, which is dated February 20 of this year. COFAR had requested a copy of the report in September and was provided by the DPPC with a redacted copy yesterday. The report concluded that Stanizzi was seriously injured as a result of an “act or omission” on the part of the staff worker, and that a charge of abuse against the worker “was substantiated.”
When Fox25 TV news first reported this incident, the chief executive officer of The Edinburg Center maintained that Stanizzi may have injured himself.
According to the DPPC report, the staff member reported that when he found Stanizzi on the floor of his room, he had a black eye, bloody nose, bruises, and a gash on his knee. The report also stated that Stanizzi was seen to have “other older injuries that did not appear to be self-inflicted,” and footprints on the back of his shins. “It is believed that staff at the group home used extreme force on (Stanizzi), resulting in the injuries,” the report stated. Another client was observed in the past tied up in a chair, according to the report.
The incident involving Stanizzi has reportedly been under investigation since September by the Middlesex District Attorney’s Office. I placed a call this morning to the DA’s office, seeking information on the current status of the case and whether criminal charges are expected to be filed. Fox25 reported in November that a Middlesex grand jury had been impaneled in the case.
The staff worker, who was the only staff on duty in the group home during the overnight shift from August 26 to 27, told the DPPC that at about 4 a.m., he had heard noises from Stanizzi’s room, but he did not check on him. Instead, he admitted that he fell asleep and woke up about 6:30, and then found Stanizzi lying on the floor on his back, not moving.
The staff worker told the DPPC he tried to get Stanizzi to stand up, but he could not, so he “lifted him off floor, put him over his shoulder and placed him back in bed.” Instead of calling 911, the staff worker tried to have Stanizzi drink juice, the report stated. The staff worker also said he tried unsuccessfully to contact two supervisors. According to the report, there was testimony that the act of moving Stanizzi without first immobilizing his spine may have worsened his injuries. The report stated that Stanizzi was “expected to be a quadriplegic,” as a result of the spinal injury.
The DPPC report noted that a police officer who responded to the home noticed that the staff worker had a fresh scratch on right side of his face and that the staff worker told the officer he had no idea how it happened. The officer said he found that suspicious. There were four residents in the home, all non-verbal, and none had aggressive or assaultive behaviors, according to the report.
The DPPC report stated that documents indicate that Stanizzi had no history of an unsteady gate or falling out of bed. The day before the incident, at a day program, the same staff worker had refused, according to testimony, to allow staff there to examine apparent abrasions to Stanizzi’s legs.
According to the report, the staff worker’s testimony changed in a number of instances. He initially denied that he had fallen asleep and later admitted that he had done so. He also admitted to having given false statements about the day program incident and about Stanizzi having hit himself in the face. The report states that the staff worker denied that he physically assaulted Stanizzi, but it concluded the truthfulness of that statement “is called into question” by the staff worker’s admission that he had lied about the other issues.
The DPPC report recommended retraining for staff and regular checks by the provider to make sure staff are awake on overnight shifts, as well as documented bed checks. While the staff worker implicated in this case has reportedly been terminated, the report recommend he not be rehired in the future.
As COFAR previously reported, an online DDS licensing report on the Edinburg Center stated that Edinburg’s two-year license to operate residential group homes was being “deferred” because of problems with medication administration. Other problems were noted in the report that required a 60-day follow-up by DDS, although there were no references to specific problems with abuse or neglect there. (As of today, the latest licensure report on DDS’s website is still dated December 2010, which would make it about a year and a half out of date. DDS licensure reports and operating licenses are valid for two years, meaning that a new report should have been posted on the website in December 2012.)
The 2010 licensure report also stated that Edinburg had been experiencing growth since 2008 and yet was “dealing with economic decline and its ongoing impact on agency services.” The report added that the provider had lost clinical and emergency services and yet had opened two new 5-person homes in FY 2010. As we noted, it seems strange that a provider would be cutting services and yet opening new homes at the same time. Opening new facilities at the same time that services are being cut may indicate that this provider may be stretched thin on its staffing, or was stretched thin as of December 2010.
The Stanizzi family has apparently filed suit against The Edinburg Center. Yesterday, I received a subpoena from an attorney for the provider, seeking all records COFAR possesses relative to the case.
When I first posted about this case here last September, I was accused in a comment by the Association of Developmental Disabilities Providers of “making accusatory statements without substantiation.”
My original post had raised questions about the staffing and management of the group home in which the injuries to Paul Stanizzi occurred. The DPPC has now found serious problems with the management and operation of this group home.
It should be noted that what happened in this case was not an isolated incident. Abuse and neglect in the group home system for people with intellectual disabilities is a recognized problem throughout the country.
We have also found it to be the case that the DDS in Massachusetts has a poor track record in monitoring care and conditions in group homes in this state. It should be a cause for concern that the online DDS licensure report for The Edinburg Center is not only out of date, but it does not address the obvious staffing issues that contributed to Paul Stanizzi’s injuries.
Thank you, dave-from-hvad for keeping us informed as to the status of the case and reminding us all, once again, of the lapses in judgement, oversight and duty of care caused by this Administration. After 8 years in – the Patrick Administration owns this. It was clear where the Governor’s heart was from the start, when he appointed the “vendor advocates” to oversee the department to oversee the DDS and DMH. And the glaring gaps in oversight wrought by his appointees and the unwillingness to understand how his policies impact the weakest of the weak should make us think very seriously about who we support in the gubernatorial race. For this population – what was the difference between the policies of Patrick vs. the policies of a Charlie Baker? Seriously. Both of them love privatization and hate oversight. What’s also shocking to me was the full-court press given to the Pelletier case (emphasis on court), when there’s a mountain of evidence showing neglect in Massachusetts group homes. Where are those lawsuits? I am going to be voting for competency in the next election….how about you?
I just got a call from MaryBeth Long, a spokesperson from the Middlesex D.A.’s office, who said an “exhaustive” review by the office “did not establish that criminal conduct had occurred.” She said that review included interviews with dozens of witnesses and an examination of thousands of pages of medical and other records.
We’re not in a position to second guess the D.A. in this case. We would just note that the DPPC did substantiate a charge of abuse against the staff worker.
Here is a full text of a statement that Long emailed to me from Middlesex D.A. Marian Ryan: