As Warford attempted to sort out the O&A center, he turned to the center's Policies and Procedures Manual. It did not define specific duties for workers. But that didn't matter. Few if any of the employees had read it.
The manual had been updated 261 times. The memos were scattered throughout the facility in various folders and offices.
Memos directed employees to stay off the phone with personal business while the children were taught by staff teachers and not to read the newspaper at work. They also reminded the staff not to curse the children.
Warford added a few memos of his own. He ordered the staff not to illegally use handicapped parking and to stop showing the children R-rated movies with full frontal nudity.
But there were much bigger issues. Warford became concerned that there was not enough staff at night, which could endanger children or other employees if there were a riot on the late shift. The night staff was supposed to check each cell every 15 minutes and log the results.
On April 3, 1997, then-Security Supervisor Gary Staggs confiscated all logbooks at 12:15 a.m. Two of the books had already been filled out to 1 a.m.
Furthermore, Staggs continued to report that the staff was sleeping at night, but no one ever seemed to be disciplined for it.
The night staff posed other problems. Security officer Kim Lynn Seals, a man, was fired April 4, 1997, after the DHS Special Investigations Unit determined that there was credible evidence of abuse. Seals had consensual sex with a 16-year-old girl at the O&A center through the cell bars, the girl said.
The girl told investigators she had sex five or six times but she did not want Seals fired. She was unhappy that he had not written her as promised. She said he had told her she could live with him and his young son. The sex occurred while other staff members were gone or sleeping, she said.
Seals denied the allegation. He appealed to the DHS Appeals and Hearing Office, which upheld the investigative findings and the firing. In September 1997, he appealed that ruling to Pulaski County Circuit Court.
In October 1997, Seals was charged in Pulaski County Circuit Court with first-degree violation of a minor. The prosecuting attorney's office decided not to prosecute in January.
Whitney and Warford were anxious to determine how many other abuse allegations had been reported and investigated. But that was impossible. Most of the reports since the facility opened had been destroyed. Rogers, the facility director, had decided the allegations were not credible and did not keep them, Warford said.
"This practice makes it impossible to monitor or review his judgment as to what should or should not be reported," Warford wrote.
Youth services counselor Marion Cronin told Warford she had filed 15-20 abuse allegations in four months. One of those reports was found in the facility. It was the only report that they could verify had been called in to the Child Abuse Hot Line as required by law and DHS policy.
"I turned in so many reports, and nobody would get back to me," Cronin told the Democrat-Gazette recently. "A lot of those kids were scared. A lot of kids did things, and they needed to be taken down -- but not beaten down. Not socking them in the face, spitting on them and calling their mothers names."
After Cronin began reporting staff members for alleged abuse, she was threatened. Memos show Cronin was moved to another floor for her own protection, but the staff member who threatened her was never disciplined.
Cronin, who left O&A in November 1997, said she called the Governor Huckabee's office 10 times in a six-week period. She said she repeatedly warned his staff that the kids' lives were in danger. She said no one called her back.
Jim Harris, spokesman for Gov. Huckabee, said, "We had talked with her but not on the topic of children's problems at DHS. It was something about her employment," he said. "Why in the world would we ignore 10 phone calls in six weeks, particularly on something like that?"
On Aug. 1, 1997, Warford concluded:
Abuse was commonly concealed at the O&A center.
Physical conflicts between staff members and children were always blamed on the child even when the staff member had acted inappropriately.
A number of staff members failed to report abuse as required by law and DYS policy.
There was a pattern of failure to discipline staff members who did not report abuse in a timely manner.
It was not clear whether Rogers was destroying these reports to prevent a proper review of the facility's reporting, but that was the ultimate result.
The O&A staff resented Warford's investigation, and most employees were uncooperative. "Bickering, control problems, stress, staff threats, misunderstandings, prejudice and animosity are pervasive throughout the facility," Warford told Whitney.
A DHS Internal Affairs investigator noted in his report: "The staff there have a 'Woe is me, things are terrible,' negative and pessimistic attitude."
Who were these people hired to supervise Arkansas' troubled children?
DYS calls them youth services workers. Starting pay ranges from $17,145 to $23,239 a year.
"The Youth Services Worker is responsible for providing direct care and guidance to juveniles," a recent job advertisement explained.
The workers are to monitor juvenile activities and behavior, provide life skills instructions, help with group counseling and assist the case manager with individual treatment plans.
Job skills required are minimal. DYS asked for: "The formal education equivalent of a high school diploma plus one year of training in a human service area or related field; plus one year of experience providing direct care services to children 12 and up.
"Applicants may be subject to verbal and physical abuse," the job notice advised.
However, applications reveal that employees generally had no significant experience with children. The DYS hired former barbers and janitors, then sent them into potentially dangerous situations with no preparation.
"O&A lacks training in key issues crucial to the well being of both staff and juveniles," Warford reported in May 1997. "The majority of the staff had not had training in the use of force, use of restraints, fire safety, gangs, first aid, CPR and policy and procedures."
Of 14 security staff members, half had no training in the use of restraints or force. Eighty-six percent had no unit management training on how to deal with and verbally calm angry teen-agers.
And among the 47 unit staff members, 87 percent had no unit management training. Sixty-four percent had no use-of-force training and 28 percent had no training in use of restraints.
In comparison, applicants for the job of correctional officer with the Arkansas Department of Correction earn a starting salary of $18,275 plus 11 percent depending on assignment. They must pass drug and criminal background checks and psychological examinations and complete a six-week training course.
The DHS requires criminal background checks for workers in privately operated state-funded youth facilities and child-care centers. But DHS did not require those safety checks at its own youth facilities in early 1997. O&A and Alexander Youth Services Center employees did not undergo background checks or drug tests before they were hired.
State police investigator Plumb had conducted criminal background checks during her David G. investigation and shared her results with Warford. Out of 118 employees, 112 were cleared.
Charles Murdock's criminal record stood out.
Murdock had been a youth services worker at the Alexander Youth Services Center from 1986-91, records show. He was fired for not showing up at work for three or more consecutive days and for having a criminal record.
"Mr. Murdock had some serious personal problems while working at Alexander Youth Services Center," Rogers wrote in 1991. "These problems should be thoroughly reviewed before he is considered for rehire."
Murdock did not report to work because he was in prison, convicted of theft by deception. He had accepted unemployment checks while he had a job for three months in 1986, records show. Two DYS employees wrote letters on state stationery to the judge on Murdock's behalf.
Murdock was a habitual offender. "Defendant Charles Murdock a/k/a Dirty Murt Murdock has been previously convicted of four or more felonies," court records stated. This was his third trip to prison.
His first brush with authorities appeared to be an absent-without-leave charge from the Air Force in 1967-68. He was court-martialed and dishonorably discharged, court records show.
Although his 1991 conviction was documented in his DHS personnel file, Murdock was rehired by the department in June 1995 to work at the Alexander facility. In October, he was hired at O&A.
Two months later, Murdock and youth services worker Lawrence Brown were accused of hitting 14-year-old Paul S. The incident was dismissed by O&A administrators. Murdock and Brown said they were merely restraining an out-of-control teen-ager.
But several boys who had recently left the center reported the incident to workers in two treatment programs, and administrators called the Child Abuse Hot Line. Then, the DHS Special Investigations Unit was alerted.
The incident began when Paul S. knocked out another boy during a fight.
Paul S. reported that while he was going back to his cell, Murdock came up behind him and punched him in the back of the head. The boy said Murdock followed him and punched him in the forehead two more times.
Brown entered the boy's cell and tried to restrain the boy by grabbing the front of his jumpsuit and holding him on the bed, records state.
Murdock entered and started hitting and kicking the boy in the chest and head, the boy testified. The boy's left eye was swollen shut.
Brown and Murdock denied hitting or kicking the boy and insisted his injuries were not extensive enough to reflect the beating he had alleged. But their stories on the incident did not match, and other teen-agers corroborated the attack, records state.
The Special Investigations Unit determined that there was credible evidence of abuse and the DHS Appeals and Hearings Office agreed. The men lost appeals in Pulaski County Circuit Court and the Arkansas Supreme Court.
Murdock was fired in April 1997 based on his criminal background. Brown was fired in January after his appeals were denied.
Last year, the Legislature mandated criminal background checks for DHS workers by the year 2000. Agencies were allowed to begin the checks in October 1997. By April 1998, the DHS had developed a process for the background checks but had not turned in the documents.
The DHS speeded up the process when attorneys were told by a Democrat-Gazette reporter in April that they had just hired convicted felon Willie Slater as a youth services workers at the O&A center.
Slater was convicted of murder in Phillips County in 1974. He was convicted in 1982 in Little Rock of keeping a gambling house, records show.
He asked DYS to allow him to keep his job because his convictions did not involve children. Slater was fired May 22.
Criminal background checks detected six employees with convictions that included third-degree battery, breaking and entering, theft of property and violation of the Uniform Controlled Substances Act, which addresses illegal drug use.
By August, Whitney and Warford had set up a training schedule for employees, hired private security guards for the evening and midnight shifts and ordered surveillance cameras. Delinquent girls were moved to Alexander to create more space at O&A. A client advocate system was established to ensure reporting of abuse allegations. Employees were reminded with posted memos to check cells every 15 minutes at night.
More than 40 employees had administrative reviews. Some received warnings; others were terminated.
Warford said disgruntled employees were using race as a smoke screen to curtail abuse investigations. O&A staff members had alleged that state police investigator Plumb was a racist and threatened a lawsuit if she were not removed from the center.
Of the two men who were her principal accusers, one resigned with five pending abuse allegations and the other was fired for selling cocaine and was under federal indictment, Warford said.
"A small but determined group of caucasians were also threatening a lawsuit if the abuse and cover up did not stop," Warford wrote in a memo to Whitney. "It was and is a volatile situation."
And when Warford began to investigate abuse and criminal backgrounds of employees, the allegations of racism were directed at him and Whitney.
Six black staff members filed complaints with the federal Equal Employment Opportunity Commission against Warford alleging discrimination. The commission dismissed all the complaints.
"The only staff [members] that had been placed on administrative leave of any race are those who had a criminal history that indicated a possible conviction for an offense involving drugs or violence or those accused of abuse," Warford stated.
By October, Whitney and Warford felt they were making some headway with the massive overhaul of O&A. And then, the unthinkable happened. One of the boys died.
He was 16 years old and his life had been a haze of drinking and drugs. At 12, he began smoking marijuana and soon added alcohol, crank and cocaine. He also inhaled gasoline, lighter fluid and butane. He frequently ran away from home. He was in trouble at school for carrying a lighter, a pocketknife and dipping snuff.
In September 1996, he stole a four-wheeler while drinking, smoking and using marijuana and crank. A year later, he broke into a house, stole some car keys, drove the car away and wrecked it. He was placed in the state's custody from Cleburne County for two felonies: residential burglary and theft of property.
By then, he had been in juvenile court eight times. He was sent to O&A on Sept. 17, 1997.
He received a letter from his girlfriend ending their four-year relationship on Oct. 15. He shared cell B-1 with three other teen-agers and slept on a top bunk where he wrote on the wall in blue-green ink: "Loved this girl & always will, but she left me while I was in here so remember love your girl and don't let one f****** thing come between you two. Peace and Love."
"WELCOME TO HELL" was among the other phrases scrawled on the wall near his bunk.
At 10:50 p.m., the boy in the bottom bunk was awakened when something hit his bed. It was his roommate's body falling to the floor.
The boy had fashioned a noose by twisting strips of cloth and braiding them. He pulled down the cover of the fire-extinguishing sprinkler in the ceiling, looped a thin part of the sheet-rope around it and let it pop back into place. Then, he placed a bigger loop of rope around his neck, leaned back in the bed and slowly strangled.
His roommate screamed for youth services worker Daphne Stedman. She saw the boy on the floor and noticed blood coming from his nose and mouth. Urine soaked his pants. She tried to call for help, but the phone didn't work.
She alerted another worker who looked in at the boy and dialed 911. No one attempted to revive him. None of the workers knew cardiopulmonary resuscitation. When the emergency crew arrived, the boy had no pulse and his pupils were fixed and dilated. He was pronounced dead at 11:10 a.m. the next day.
When the boy first arrived at O&A, he did not admit to suicidal tendencies. The facility had asked Rivendell Psychiatric Center to forward the boy's evaluation records on Sept. 22.
The Rivendell records arrived at the center 18 days after his death.
The files showed that the boy had been referred to Rivendell in 1994 after he attempted to overdose on drugs. "He admits that he had subsequently thought of suicide by attempting to hang himself," his file stated.
The DHS, with help from the state police and the medical examiner, investigated the boy's death and determined there was no foul play.
On Nov. 25, 1997, Warford fired Stedman.
"I have reviewed the record concerning the suicide at Central Arkansas O&A, the incident at the school, and a number of other incidents that occurred during your probation period," he wrote.
"I have found a number of violations of DHS Policy 1026 as well as general unprofessional conduct in dealing with juveniles."
After the suicide, Warford demanded that the cells be checked every 10 minutes. He reminded workers that many of the juveniles were emotionally disturbed.
But employees continued to sleep on the job. In December, Warford went to the O&A center at 3 a.m. and said he had to shake an employee awake.
The dazed man demanded, "Who the hell are you?"
"I'm Lloyd Warford. Try to stay awake," the DYS director of operations replied.
Still, the sleeping continued. Some workers denied they had been sleeping on the job. Warford returned with a camera and took pictures to document the problem.
The employees were given two-day suspensions in accordance with DHS procedures.