WHAT THE INVESTIGATORS FOUND

LITTLE ROCK — A partial list of problems cited by state and federal investigators at the Conway Human Development Center 2001-02.

Copies of these reports can be obtained by contacting (501) 682-8677 at the state Department of Human Ser vices. Office of Long Term Care Feb. 22, 2001 **** • Failed to protect 10 residents from unwanted sexual aggression by a fellow resident. • Failed to promptly evaluate and increase the dosage of anti-seizure medicine for one resident. The 17-year-old boy experienced seizures that could have been prevented from Aug. 15, 2000, through Oct. 6, 2000, and from Oct. 28, 2000, until he was hospitalized on Jan. 5, 2001. Centers for Medicare and Medicaid Services April 13, 2001 **** • Failed to ensure the protection of residents from repeated injuries, unwanted sexual advances and aggression from 11 other residents.. • Failed to report the following incidents of possible abuse to the Office of Long Term Care and the Attorney General's Office. - Resident reported being pushed down by a staff member on July 24, 2001. Resident had bump and bruise on her forehead. - Resident reported being "head butted hard" by staff member on Sept. 2, 2000. - Resident reported he was choked by staff member on Oct. 26, 2000. - Resident had 19 aggressive acts toward other clients over six months. - Sixteen acts of aggression were against two clients living in his home. - Thirteen of those incidents resulted in injury. - The behavior program for the aggressive client was revised, but the revisions were not put into place. - Resident had bitten fellow residents 18 times, requiring medical care, over four months. Behavior program updated but included no substantive revisions for staff in controlling his behavior. After two medication changes, the resident caused nine other biting injuries. No subsequent changes were attempted. - Failed to investigate injuries of unknown origin to rule out possible abuse or neglect by staff for 18 of 19 residents. - Injuries included 13 cuts requiring stitches; six fractured fingers, toes or hands; one broken tooth. - Staff must not use physical or psychological abuse as punishment. - Resident had to assume a kneeling position and touch his forehead or nose to the floor with his hands clasped behind his back. The team psychological examiner stated that she "believes it's humiliating and demeaning, but it works." University of Arkansas for Medical Sciences April 2001 A report on the strengths and weaknesses of medical care at the Conway facility by members of the Department of Pediatrics. Covers a variety of issues including: • The need for additional training for medical staff. • Outside peer review for the center's two doctors. • A nurse specifically trained in infection control. • The need for written standards for numerous medical practices. The report recommends "a complete reassessment of the goals and objectives of the Conway Human Development Center." Office of Long Term Care • Staff failed to protect residents. - On separate nights, staff left two residents - a woman and a 9-year-old boy - unattended for an undetermined length of time. No one could explain how or why each of their feeding tubes got turned off. This resulted in physical and psychological harm to the woman, the report states. - Resident walked away and was gone for 19 hours. The facility did not know he was missing. - Resident wandered off and was hit by a car. He suffered compound fractures of both legs and fractured his arm. Facility did not know he was missing until called by the police. Office of Long Term Care June 15, 2001 • Failed to ensure resident protection. - Resident ingested hand sanitizer. - Staff turned away and resident fell off bed, breaking collarbone. Centers for Medicare and Medicaid Services June 27, 2001 Two injuries of unknown origin were not reported as the center promised to do after an earlier investigation. - Resident's head was cut on June 8, 2001. - Resident's penis was bruised May 10, 2001. Office of Long Term Care Aug. 2, 2001 **** • Failed to provide supervision to prevent sexual abuse of residents. • Failed to ensure that eight of 50 sampled residents had a continuous active treatment program. Active treatment includes training residents in daily living skills. • Failed to set goals to reduce psychotropic drugs or establish a plan to determine if the drugs were helping 14 of 19 residents whose files were pulled randomly. The facility was ordered to hold special meetings to update files on 225 of 250, or 90 percent, of residents using those drugs. Office of Long Term Care Aug. 30, 2001 • Failed to set goals to reduce psychotropic drugs or establish a plan to determine if the drugs were helping 10 of 14 residents whose files were pulled randomly. This was a continuation of the problems cited above. Centers for Medicare and Medicaid Services Sept. 28, 2001 • Failed to inform guardians and failed to obtain consent to use restraints for medical and dental procedures for eight of 50 residents whose files were reviewed. • Failed to provide active treatment for 18 of 50 residents whose files were randomly reviewed. Office of Long Term Care Dec. 7, 2001 **** • Failure to protect residents. - While escorting two residents, one of them blind, another in a wheelchair, to the chapel, a staff member took a shortcut and both residents fell. One resident suffered a nasal bone fracture. • Staff was not trained sufficiently to identify cases of abuse when there is not physical injury. - One employee reported another employee pulled a client's hair with enough force to jerk her head back. The facility labeled the incident "discourteous treatment," but investigators determined that it was "abuse." Office of Long Term Care Feb. 13, 2002 • Nursing services. - A doctor was not notified immediately of significant changes in the medical condition of two of three residents. One resident died the same day. Another died two days later. An investigation of these deaths does not state if the deaths were related to the failure to alert the doctor. Office of Long Term Care June 7, 2002 **** • Failed to ensure that all allegations of client abuse, neglect and/or maltreatment were reported to appropriate authorities and an investigation into the allegations was performed. - A resident told his mother that a male staff member had been "messing with him" sexually. The resident had previously told this to another staff member. She did not report it. - A Conway center policy requires a five-minute break every 55 minutes for residents placed in restraints. That policy was violated 11 times in six months for one resident who was restrained as long as 85, 90 and 105 minutes. Federal law requires that the resident be released every two hours. The chief psychologist at the center told investigators he believed residents could be restrained "indefinitely" without a break if they were not calm. - The Conway center hired a licensed practical nurse who had previously been fired from the center for mistreating a resident. - Staff members facing abuse and neglect allegations were supposed to be separated from residents. But over six months, 15 staff members accused of crimes were placed in the kitchen and laundry areas where seven residents worked. - Failed to ensure that feeding tubes were flushed before and after medication was administered for 10 out of 10 clients observed. - Failed to label drug containers based on accepted standards of practice, which included precautionary instructions and expiration dates.

The Office of Long Term Care is a state entity. The Centers for Medicare and Medicaid Services is a federal agency.

**** A serious deficiency that could result in the loss of federal funding.