(Cross-posted from The COFAR Blog)
More than three years after the sudden death of a former resident of the Templeton Developmental Center, we have received a report on the matter from the state Disabled Persons Protection Commission, which found that the resident had adequate care and services at the time of his death and that there was no evidence he had been neglected or abused.
But the report is so heavily redacted that it is difficult to determine whether a number of specific questions and allegations that had been raised about the person’s care were actually investigated. It is also unclear why it took nearly two years for the DPPC to provide us with the report, which was completed and approved by a supervisor in the agency in November 2012.
The former Templeton Center resident died on July 24, 2011, four days after he was transferred to a state-operated group home in Tewksbury. The cause of death was reportedly a blood clot in his lung.
This was one of three cases we heard about in 2011 and 2012 in which clients of the Department of Developmental Services, each of whom happened to be a man in his 50’s, died suddenly after being transferred from developmental centers to state-run group homes operated by Northeast Residential Services, a division of DDS. A second case was that of a former resident of the Fernald Developmental Center, who died on July 6, 2011, after having ingested a plastic bag in a Northeast Residential Services group home in which he was living in Tyngsborough.
In that second case, a DPPC report concluded that there was a lack of adequate supervision of the man by his caregivers, although the investigative agency was unable to determine whether the man had ingested the plastic bag while he was in the group home or his day program or was being transported between the two. That report was also so heavily redacted that it left numerous questions about the incident unanswered for us, including whether the man’s care plan may have been significantly changed after he left the Fernald Center.
In a third case, a 51-year-old resident of a Northeast Residential Services home in Chelmsford died of acute respiratory failure 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. We have just requested that report from the DPPC.
While it is of course disturbing that three DDS clients would die suddenly in a relatively short span of time in the same regional group home system, we have no information to indicate that staff in any of the Northeast Residential Services homes were at fault in any of the deaths. These cases may in fact raise more questions about the DPPC’s investigation and reporting procedures than they do about care in DDS-run group homes.
In the case of the man who died of a blood clot four days after leaving Templeton, we raised questions at the time whether the stress of the move may have contributed to his death, or whether there was a medication error or other care issue involved. It was also unclear whether staff familiar to the man while he was at Templeton was available to accompany him to his new residence in Tewksbury. Moreover, we noted that DDS may not have had uniform policies or procedures in place as to whether familiar staff should accompany transferred residents to their new locations.
The DPPC report found that the man had direct-care staff available 24 hours a day and nursing staff “as needed” in his group home, and that there was no evidence that any medication error had occurred.
I have written to the DPPC to ask why it took so long to release the report on the former Templeton resident’s death. I had requested a copy of the report by letter on October 31, 2011. The report is dated as having been completed on November 1, 2012, and as having been approved by a DPPC supervisor that same day. It was mailed to us with a cover letter, dated September 17, 2014.
In contrast, the report on the July 2011 death of the former Fernald resident who ingested the plastic bag, while also heavily redacted, was dated March 29, 2012, and provided to us in May of 2012.
The former Templeton resident’s guardian, who was also his niece, told me after his death in July 2011 that her uncle had had a blood clot in his leg about a year before the move from Templeton (deep venous thrombosis), but the problem had been cleared up. She said he had been put on a blood thinner called Coumadin, but that she later found out that he was taken off that medication while he was still at Templeton. She said she was never consulted about the decision to take him off the medication. The guardian said that other than the instance of thrombosis, her uncle had only minor health problems. He had worked every day in the dairy barn at Templeton.
While most of the discussion in the DPPC report on the issue of the former Templeton resident’s medication appears to have been redacted, there was a statement in the report that “all necessary medications were continued,” and that a review of documentation from July 19 through the day of his death on July 24, 2011, “indicates no medication error occurred.” Due to the redactions, however, it could not be determined from the report which medications the DPPC considered to be necessary. There was no mention in the unredacted portions of the report of any allegation that the Coumadin had been discontinued.
The guardian had also told me the staff from the group home had spent about a week at Templeton with her uncle prior to the move, but she was not sure whether any familiar staff from Templeton accompanied him during the actual transfer to the new residence. The unredacted portions of the DPPC report were not clear concerning this potential allegation either.
According to the DPPC report, the man’s move from Templeton to the Northeast Residential group home had been planned, and staff from both facilities attended the planning meetings. The resident was actively involved in choosing the new residence and visited it along with familiar staff and family prior to moving there, the report stated.
In discussing the circumstances of the man’s death, the DPPC report stated that he had left his bedroom at 9:15 on the morning of July 24, 2011, and had indicated he was not feeling well. Three staff members responded immediately. The man became short of breath and then unresponsive, so CPR was initiated immediately and 911 was called. CPR was continued until the arrival of paramedics, who continued it while the man was transported to a hospital by ambulance. He was pronounced dead at 9:47 a.m.
The March 29 DPPC report on the death of the man who ingested the plastic bag also leaves many questions unanswered about his care, including whether the man’s Individual Support Plan (ISP) had been 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, was redacted in the report.
The man reportedly had a history of ingesting foreign objects, a condition known as pica. However, even what was apparently the word “pica” was redacted throughout the report.
It is understandable that public health and human service agencies have a desire to protect the privacy of individuals in their care or their jurisdiction. But it often seems that the desire to redact or withhold information goes much farther than necessary and fails to protect the public’s right to know about these cases. In our view, the two DPPC reports discussed here fall into that latter category. We believe much of the redacted information in both cases could have been made public without compromising either of these individuals’ privacy in any way.
The questions raised about the care and services that were investigated in these cases are important ones. Something seems to be wrong when investigative and other agencies withhold key facts about cases like these and end up being the only ones who know those facts.
