Some incidents that the Conway Human Development Center classified as 'discourteous treatment' are actually abuse, the state says.

Monday, June 24, 2002

— She was having a bad day. And on Sept. 19, 1998, everyone around her had one, too.

Jane (not her real name) had worked nearly two years as a life-skills trainer at the Conway Human Development Center. Her job was to feed, bathe, dress and tend to some of the nearly 600 mentally retarded and physically dependent residents.

But by the end of her shift on living unit 15 Cypress, co-workers claimed she had: Hit a woman resident on the head with a hairbrush.

Squeezed the back of another woman's neck hard enough to bruise it.

Force-fed a third woman, who struggled to keep the food out of her mouth.

Placed a fourth woman in a headlock and poured milk down her throat saying, "You're going to drink or drown."

After an investigation, center Superintendent Bob Clark determined that there was no evidence of adult maltreatment.

If he had determined that it was abuse and the state Office of Long Term Care had agreed with him, Jane would have been placed on a statewide employment clearance registry. She would have been forbidden to work in nursing homes, human development centers or other long-term care facilities.

Clark relied on an internal investigation and a Conway center commit- tee that concluded that Jane had "threatened, intimidated, coerced and demeaned" residents and needed to be fired.

But Jane, the committee wrote, was feeling sick with a low-grade fever and lacked the "intent" to harm anyone.

Clark terminated Jane for various counts of "discourteous treatment." That is a lower level of offense than abuse.

As a result, Jane was only prohibited from working for the state Department of Human Services.

Jane pleaded guilty in Faulkner County District Court in 1999 to harassment, a misdemeanor. Because of that conviction, she can no longer work at any long-term care facility in Arkansas.

Questions persist over what actions rise to the level of abuse at the Conway center.

Since February 2001, the Conway Human Development Center has been criticized by state and federal regulators for not reporting abuse.

The Arkansas Democrat-Gazette has analyzed the records of eight investigations conducted since 1998 and categorized by Clark under "discourteous treatment."

Because of client confidentiality, employees are not allowed to discuss what happens to residents at the center. Details and interviews were derived from documents obtained under the state's Freedom of Information Act.

Incidents witnessed by other staff members included these:

In June 2000, a male staff member sat on a male resident's face in bed.

In October 2000, a woman resident, unable to speak, was left naked and locked in an empty whirlpool bath for up to 30 minutes while she bit herself in frustration.

In January 2001, a woman resident was slapped several times by a woman staff member, was called "titty baby" and then mocked for wetting her pants.

In August 2001, a male resident was thrown "forcefully and hurriedly" onto a bathing slab so two workers could watch the Source Hip-Hop Music Awards.

One of those workers teased a resident who wasn't feeling well by flipping the resident's lips with his fingers. He called another resident "Big Head," referring to the resident's physical problems, records stated.

"What Conway calls discourteous treatment in certain instances, we call abuse," said Frank GoBell, assistant chief program administrator for the state Office of Long Term Care.

That office investigates complaints of abuse, neglect or misappropriation of resident property.

The state Adult Abuse Act, Arkansas Code 5-28-101 describes abuse as "any intentional and unnecessary physical act which inflicts pain or causes injury to an endangered or impaired adult" and "any intentional or demeaning act which subjects an endangered or impaired adult to ridicule or psychological injury in a manner likely to provoke fear or alarm."

In fact, "There is no state law on discourteous treatment," GoBell said. But there is a state Department of Human Services policy listing minimum codes of conduct for employees. That is the policy Clark cited in the Jane case.

Carol Shockley has been director of the Office of Long Term Care since April 2000. Her office upgraded four of the discourteous-treatment findings to abuse.

"They were serious incidents. The cases we've reviewed were clearly abuse."

"The issue is, that Conway Human Development Center doesn't recognize these cases as abuse. The fact that they have called abuse 'discourteous treatment' is troubling," she said.

The woman in the wheelchair was being difficult.

She often screamed to get attention and, like a child playing "fetch" with her parent, she repeatedly threw a purple hairbrush on the kitchen floor on that Saturday, Sept. 19, 1998.

Jane, then 20 years old, told a Conway center investigator what happened next. "I took the brush and tapped her on the head."

"I wouldn't call it hitting. I popped her like 'Goofy, don't drop it again.' I'd picked it [the hairbrush] up 15 times already, and it was not intentional to hurt," Jane said.

But a co-worker had a different version for the investigator.

Jane "picked up the hairbrush and hit her in the head... loud enough to make a pop," said life-skills trainer Sharon Martin.

Jane also was asked about whether she squeezed the back of a resident's neck hard enough to leave a bruise. She responded that she touched the resident "lightly."

"It was out in the day room after supper and she [the resident] kind of yelps. I was told by another person that if you put your hand on her neck she'll quit."

Martin provided another version of the incident.

"She [Jane] put her left hand on the [resident's] neck and squeezed it real hard and said, 'This is how you get her not to holler.'"

But the resident screamed. "She went 'ahhh,'" Martin said.

An examination in the center's infirmary revealed a bruise on the resident's neck.

An incident report was written on the two events.

But it was two other events that same day, not mentioned in that incident report, that cost Jane her job.

The first began when Mary Holland, a licensed practical nurse, was giving medicine to a woman resident during the resident's evening meal.

The woman drank two large glasses of juice and stopped eating after a few bites. Holland asked Jane if she could get the woman to eat some more.

"As I was leaving I heard [Jane] say, 'If you don't drink this milk, I'll pour it down your throat.' I thought she was teasing, I really did," Holland told an investigator.

But a short time later, Holland learned that the resident had become very upset and was being placed in a helmet restraint to prevent self-injury.

Holland returned to the day room and asked, "Why did she have to have this [helmet] because she was perfectly fine. I just left her a few seconds ago."

Martin told investigators that Jane took the top off the milk, held the resident's head back and said, 'You're going to drink or drown.'"

"She [Jane] was dumping it to the point where [the resident] was making a gasping noise.... [The resident ] was spewing it all over her clothes. She was biting. She was fighting."

Martin tried to calm the resident. "She was biting herself, biting at me.... By this time she was irate, and I don't blame her."

Martin had a "mask" put on the resident to protect her from injuring herself or others. When the woman calmed and the mask was removed, her chin was bleeding. "She just kept raking her face, and it [the mask] just cut it on the bottom," Martin said.

Jane denied forcing milk down the woman's throat.

"I gave her milk, and she wouldn't drink through the straw. So I took the top off and... she holds her head down, so I was holding her head up and trying to give it to her... I wouldn't say force. ... She was spitting it out."

What would she have done differently, the investigator asked.

"Next time, if she doesn't drink through the straw, she just won't get it," Jane replied. "She's my baby. I love her to death. I did not intentionally try to hurt her."

But Jane had more explaining to do.

Martin saw Jane with another woman resident, and thought "She was feeding her a little rough."

Jane said the resident wouldn't eat for another worker, so Jane tried to feed her. "I put food in her mouth, she spit it out. I put food in her mouth again, she spit it out again, and she started scratching me."

Martin said it was more complicated than that.

Jane "was forcing her to eat, and the resident took her finger and was trying to pull the food out of her mouth. And [Jane] grabbed her hand and told her she wasn't going to do that. And then the resident tried to claw at her, and she grabbed her again... and continued to force feed her."

Nurse Holland also saw Jane and the resident grappling.

"The resident was trying to bite her hand and yelling and fighting with her good hand, and [Jane] was trying to force food into her," she said.

Martin calmed the resident and got her to eat.

Later, Martin told an investigator that she confronted Jane. She warned Jane that she was going to report her.

"We are the only voice for these little girls that they have," Martin scolded her. "We are the only ones."

Martin quoted Jane as replying that she didn't know she was doing anything wrong.

"How did you not know you were doing something wrong when you've got 'em in a headlock? How do you not know you were doing something wrong when you were cramming food down someone's throat," Martin demanded.

The Conway center's Human Rights Committee reviewed the incidents and concluded that Jane "was abusive in her language and improper in her treatment of four individuals. ... Her behavior was discourteous - uncivil, barbarous - to a dangerous extent. Therefore, she no longer deserves an opportunity to work with people less able than she. She can no longer be entrusted with their care."

The committee report added that the happenings that day were an "isolated incident" for Jane, and the committee did not believe Jane had an "intent" to cause physical or psychological injury to anyone. That ruled out a finding under the Adult Abuse Act.

Jane was fired Oct. 8, 1998, for discourteous treatment.

She pleaded guilty to one charge of harassment in September 1999. She was later placed on the state registry barring her from working in long-term care facilities in Arkansas.

On any given day, John could be seen maneuvering his electric wheelchair through the halls at the Conway Human Development Center.

Despite his mental retardation and spastic cerebral palsy, he communicated by talking and often visited the nurse when he had questions about his health.

John (not his real name) was usually cheerful. He was a registered voter in Faulkner County. (State law says an otherwise qualified person may vote and is free of discrimination because of any sensory, mental or physical disability.) He was a consumer member on the Human Rights Committee. "He prides himself on being as independent as possible, in spite of his handicaps," one evaluation stated.

However, John needed help from the staff to bathe, dress, brush his teeth and get into his higher-than-normal bed.

On June 10, 2000, a visibly upset John approached supervisor Debbie Hooper and asked to speak to her in private.

He told her that Blake (not his real name), a life-skills trainer, had climbed into his bed the night before and sat on his face.

John asked him what he was doing and said Blake replied that they were "doing like they do in a wrestling match."

A bizarre scenario emerged as investigators traced Blake's action that night. Around 6:30 p.m., staff member Judy Harper was working a puzzle with two residents when Blake and John walked into the day room.

As they entered, Harper heard Blake say, "You get on back there and get ready for a bath. You stink, your chair stinks, and everyone can smell you."

Blake told John that if he didn't go back for his bath, Blake was going to show him "a stinky face."

Blake then pulled his black, lightweight, jogging pants "all the way down" and exposed his buttocks to everyone in the room, two staff members said.

He ordered John "Now get your ass back there and get your bath," Harper said.

"The look on [John]'s face was unreal. It really bothered [John]," according to Brenda Babb, a staff member who talked with a Conway center investigator.

Babb and Blake gave John a bath and lifted him into his bed.

A few minutes later, Babb was sorting clothes across the hall from John's room when she heard him yell. Babb looked up.

"From what she could see, [Blake] was propped up on the bed with his hind end in [John]'s face," records stated. Babb said she was in shock and just stood there.

Afterward, Blake went into the back hall and told Babb that he had split his pants "acting stupid." He told other staff members that he ripped his pants putting John to bed.

Babb went into John's room to check on him. She said Blake had not physically hurt John, but "mind-wise it bothered him."

"He kept telling me that he was disgusted that [Blake] had done that to him," Babb said in a written statement.

John said he talked to the supervisor about the incident, "because it scared me, I just thought I would tell somebody. I was real surprised that he would try something like that."

Blake, who had worked at the Conway center for a year, denied re-entering John's room after putting him to bed.

He also denied making rude comments to John about his body odor.

Instead, Blake recalled asking John: "Do you mind if we do this, because you do have a slight body odor problem."

Blake said "I didn't say 'You stink,' because I wouldn't want someone to say that to me."

A few days after the incident, Harper told the Conway center investigator that Blake called her at home. He wanted to know if she was going to talk to an investigator about the incident.

Harper said she refused to discuss it with him.

"He told me, 'Just remember whatever you tell, I won't forget it. You remember that,'" Harper wrote in a memo. Harper said she hung up on him but kept her caller ID to verify that he had made the call.

On June 22, 2000, center superintendent Clark closed the file, concluding "that adult maltreatment cannot be substantiated."

Clark did determine that Blake "has acted in a very discourteous manner toward John by exposing his buttocks and utilization of demeaning language."

"Note is also taken that [Blake] has made a 'threatening' phone call to at least one potential witness," Clark wrote.

He ordered Blake fired "for multiple episodes of severe discourteous treatment." He cited general DHS policy plus "Webster's New Collegiate Dictionary," which defined discourteous as "a rude act."

In an e-mail in response to the Democrat-Gazette, he noted, "It was concluded that [Blake's] action were: He partially 'mooned' several staff and clients in the dayroom area and he sat on client's head (fully clothed) for a brief period.

"It could not be concluded that [Blake] made contact of a 'sexual' nature with any client or staff person, and it was obvious to this investigator and this reviewer that he was being 'rude and obnoxious.'"

Long Term Care upgraded that finding to "abuse" on Aug. 10, 2000. Blake was added to the employment clearance registry and can no longer work in any long-term care facility in Arkansas.

"It is tremendously important that incidents be properly classified from the beginning," said DHS spokesman Joe Quinn. "An abuse allegation triggers certain actions. Notifications are made to other agencies to look at the incident. It is critical to our system of protecting the residents.

"Those things do not happen when an allegation is labeled 'discourteous treatment.' It is handled internally."

Michael Whitfield had worked about six weeks on 1 Willow, the unit for medically fragile men, when he suddenly resigned.

He told his supervisors he couldn't handle the stress anymore. He said he was worried about how some staff members treated the residents.

For Whitfield, the indignities to the people he had chosen to care for began on Aug. 28, 2001. Between 7 p.m. and 8 p.m., a woman life-skills trainer asked him to help her give a male resident a bath.

"I was looking around for someone else (to help us) because he is a big guy," Whitfield told an investigator.

He approached life-skills trainer Tommy (not his real name), who was watching a TV music awards program.

"Just a minute," Tommy replied.

TV logs list the Source Hip-Hop Music Awardsas being on during that time period. Tommy waited until a commercial break before finally going to their aid, Whitfield said.

"We were standing by the resident between three and seven minutes," Whitfield said.

Tommy asked Roy (not his real name) to help. Roy had been watching the TV program with Tommy.

Whitfield explained what happened next. "We got in there and I offered my assistance and they just say, 'move.' They very forcefully and hurriedly picked the resident up and dropped him onto the slab. And ran out of the bathroom before the commercial break was over."

How did they transfer the resident from the wheelchair to the bathing slab?

"One of them was at the top of the torso, had him underneath the arms and the other had the knees and thighs. And just 'boom' and ran out. I mean, that quick."

The resident's individual program plan stated that he is afraid of being lifted, and the staff should always explain what they are doing to alleviate his fears.

The resident was not able to talk but communicated by facial expressions.

"I don't know if it was from physical pain or just from the stress of being handled so carelessly, but his mouth was open, he was moaning and he began to shake," Whitfield said.

Tommy said he did not remember much about that evening. But he denied hurting any of the residents.

"I do remember the Source awards being on and I do remember going back there and helping him. But as far as yanking him up and slamming him down, NO."

And what about the resident moaning ? "In my observation, he was no worse than he usually is. If you pick him up... he still has a tendency to where he will stiffen his legs and he will shake and like a freeze-up type of motion."

Whitfield said he had another problem with Tommy on Sept. 7, 2001, that also involved lifting a resident. He said he and another employee asked Tommy to help lift a 5-foot-9-inch, 163-pound man.

Whitfield said Tommy refused. Whitfield fell to one knee while he and the other staff member were lifting the resident. The resident was dropped to the floor, but was not hurt.

Tommy said he didn't help right away because, "There was nowhere for me to grab. ... The way they had the wheelchair sat, was next to his chair and I could not get in there to help them," he said. "There was no refusal."

Tommy said his supervisor had talked with him previously about refusing to help others with residents. "I've probably gotten seven complaints of me for refusing people. I'm like, I don't understand, like within two months, everybody has a problem saying I'm refusing them."

"This is not making sense. I am NOT [refusing to help others]," he said

Whitfield said he saw Tommy teasing a male resident that same night.

"The resident was in his recliner in the dayroom. He had been cranky and not feeling well," Whitfield wrote in a memo. Tommy "goes behind him and takes his own finger and began to move the resident's lips up and down. The resident was obviously aggravated, but [Tommy] persisted."

Whitfield described the resident's reaction as, "Eck, no."

He told an investigator that if any of these incidents had happened to his relatives, "I'd have felt outraged."

Tommy denied teasing the resident. "I don't play with him like that," he said.

He did recall calling a resident, "Big Head."

On Sept. 25, 2001, center superintendent Clark determined that "Adult maltreatment is not founded based on lack of credible evidence."

Instead, he fired Tommy for numerous counts of discourteous treatment toward staff and a client in living unit 1 Willow and failing to perform assigned duties in an efficient and productive manner.

Roy was given a written warning for failing to perform assigned duties in an efficient and productive manner. "These actions border on 'Discourteous Treatment,'" Clark wrote.

The Office of Long Term Care reviewed the investigation and upgraded both Tommy's and Roy's actions to "abuse." Both men went through the appeals and hearing process.

Tommy was placed on the employment clearance registry April 2002; Roy on June 2002.

They are barred from working in a long-term care facility in Arkansas.

The memo was a warning: Abuse is to be called abuse.

On Feb. 14, 2001, David Long wrote to the state Developmental Disabilities Services Division under which the human development centers operate.

Long is an attorney for the Office of Chief Counsel, which provides legal advice to the divisions of the state Department of Human Services.

"Findings were being made of discourteous treatment under DDS policy where residents were slapped, but no reporting of the incident of abuse was made to the Office of Long Term Care."

The failure to report properly will be cited as a deficiency, he stated.

There were more incidents to come.

On Sept. 13, 2001, a life-skills trainer was seen by another staff member pulling the hair of a woman resident with enough force to pull the woman's head back, records stated.

The woman was repeating, "Wait for mama," and it irritated the employee, records stated.

The Conway center determined that the action was "discourteous treatment." The employee was suspended for five days and scheduled for retraining in the area of resident rights/abuse.

On Oct. 18, 2001, the Office of Long Term Care upgraded the "discourteous-treatment" report to abuse. The employee's name was placed on the employment clearance registry. Attempts to reach her for comment were unsuccessful.

Based on that incident, the Office of Long Term Care cited the Conway facility on Dec. 7, 2001. It stated that employees who investigate allegations are not trained effectively to identify abuse when there are no physical injuries visible.

"The facility respectfully disagrees," the Conway center responded. Deputy Editor Frank Fellone supervised this series.


Medical care at the Conway Human Development Center.

Copyright © 2002, Arkansas Democrat-Gazette, Inc. All rights reserved.