Before covid-19 outbreaks threatened two state-run homes for people with disabilities, records show regulators flagged the centers for endangering clients while using physical restraints -- a controversial yet common practice to defuse tense situations.
An ongoing Arkansas Democrat-Gazette review of documents from Conway Human Development Center and Booneville Human Development Center found five cases in which inspectors said facilities violated federal standards when staff members restrained clients, with some cases amounting to abuse.
A client at Booneville suffered a broken arm when a staffer restrained him in July 2019, and another lost consciousness in January that year when a staff member placed him in a "choke hold," inspectors said in reports.
A staff member at Conway threatened to restrain a female client all night if she didn't "shut up," an October report said.
Department of Human Services, police and prosecution reports obtained under the state's public-records law provide a window into facilities entrusted with the welfare of vulnerable Arkansans. They show recurring issues in cases involving both personal and "mechanical" restraints, such as a board with straps called a papoose board.
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Sometimes, the facilities broke rules meant to limit restraint use in care facilities that receive federal payments from the Medicaid program, inspectors wrote in their reports. At other times, they didn't meet standards meant to protect clients from abuse during events involving restraints.
Division of Developmental Disabilities Services Director Melissa Stone said the events described in the documents were "self-reported" by the centers. She described them as "isolated incidents" that "should be categorized as abuse not a personal restraint gone wrong."
"What happened was not in compliance with our training and we considered the behavior maltreatment of our clients," Stone wrote in an email. "Maltreatment of clients is never OK, and individuals involved in the cases were immediately placed on administrative leave and all were terminated as I understand it."
Four of the five incidents the newspaper reviewed drew inspectors' most serious citation, "immediate jeopardy," which is for events that put clients "at risk for serious injury, serious harm, serious impairment or death."
On Friday -- after the newspaper reached out to the Department of Human Services about its findings -- Stone wrote to the head of an Arkansas disability-rights watchdog describing "additional steps" the state will take to assess restraint usage, including tracking personal restraint and reviewing treatment plans and devices.
About 880 people live in five state-run residential treatment centers for residents with developmental disabilities and, sometimes, other health or mental-health issues. Conway Human Development Center is the largest, with 460 residents.
Like other long-term care settings, the centers have drawn scrutiny this year because of the risk of quick viral spread in group living environments. Conway and Booneville endured the largest outbreaks, with 142 and 89 total resident cases, respectively, Arkansas Department of Health data from Sept. 4 show.
A 66-year-old client of the Southeast Arkansas Human Development Center in Warren died of covid-19 in August, coroner's records show, the facilities' first such death.
Inspectors visiting Conway Human Development Center in June for a review prompted by the pandemic gave the facility good marks for its infection control practices but noted a problem for one client, who was strapped to a papoose board during the visit.
The client was "quietly looking" at a staff member, the inspector wrote. When asked how long the client had been restrained, the employee replied: "Thirty minutes. She still has twenty minutes to go."
That breached federal standards about releasing clients from restraints "as quickly as possible," an inspector wrote. And it ignored internal policy about when residents should be released from restraining devices -- "when calm," the inspector wrote.
Records suggest a pattern of similar infractions that stretches back at least 18 months, including three since 2019 that led to criminal convictions.
Twelve months of state data -- from August 2019 through July -- also shows the five human development centers aren't consistent in their use of restraints, even when considering population sizes.
At Conway, which has a bit more than four times the population of the Jonesboro center, mechanical restraints including a restraint chair, the papoose board and a restraining wrap were used 1,074 times compared to Jonesboro's 92 times, data shows.
An analysis over a different yearlong period provided by the Department of Human Services showed a rate of use at Conway that is nearly five times that of the Arkadelphia center, though others were closer.
Across all five facilities, mechanical restraints were used on residents 148 times in July as the pandemic surged, according to state data: four times at Jonesboro, eight times at Booneville, 12 times at Warren, 14 times at Arkadelphia and 110 times -- or more than three times a day -- at Conway.
Documents and data reviewed by the newspaper weren't comprehensive and did not include documents from each individual use of restraints.
Personal restraints, which involve a staff member's hands or body only, haven't been consistently tracked by the centers, and this review by the newspaper did not extend to "chemical" restraints including antipsychotic and other drugs.
The state watchdog group, Disability Rights Arkansas, noted similar issues with restraints at Booneville in 2015 and 2016, including them in a 23-page report that called for reforms to correct a "culture" of "excessive" restraint.
Its director, Tom Masseau, said in an interview that he thinks the public sometimes doesn't understand what it means when restraints are used at the human development centers, including in cases where residents were injured or otherwise harmed.
"If that happened in your own home, to your kid or your loved one, you would be under investigation. But if it happens to somebody in an institution, we just sweep it under the rug and call it a behavioral issue," he said.
"We really haven't gotten down to the bones of, why do we allow this to continue?"
Witnesses to the July 2019 incident at Booneville told an inspector that they'd seen a resident with an intellectual disability and schizophrenia begin hitting a staff member. The staff member allegedly responded by twisting the resident's arm behind his back in an "emergency personal restraint."
"You're not gonna hit me. I'll [expletive] your world up," the staff member reportedly told the resident. Witnesses heard a "crack" or a "pop," they said.
An X-ray later showed the resident's arm was broken.
REDUCING USE
Restraints are permitted in many care settings, including intermediate care facilities such as the human development centers, but experts and advocates have questioned their continued use, citing the danger of injury, inconsistent data collection and scant evidence of their therapeutic usefulness.
As early as 2003, a federal mental health agency issued a "call to action" to reduce the use of restraints and seclusion. (The latter practice of isolation isn't allowed at intermediate care facilities, a Centers for Medicare and Medicaid Services spokesman said.)
A government report from that same year says both restraint and seclusion carry "risk for serious injury or death, re-traumatizing people who have a history of trauma, loss of dignity, and other psychological harm" and should only be used as a "last resort."
Current Centers for Medicare and Medicaid Services guidelines say intermediate care facilities must develop policies around restraint use and provide "active treatment" to "reduce dependency" on the tools, as well as on "unnecessary drugs" to manage clients' behavior. They also must make sure their use of restraints doesn't violate mandates to keep residents safe from abuse and neglect.
Some states have enacted more stringent standards than the federal guidelines on restraint use. Arkansas has not.
Stone said the state has a plan, updated annually, to reduce restraint use, and provided each facility's restraint policy to the newspaper. Restraints at the human development centers are "not used therapeutically," but in "emergency" situations where clients may harm themselves or others, she said.
She added that staffs are trained in deescalation techniques and that a committee was created in 2017 in response to reports of excessive restraint usage at Booneville. Led by a psychologist, the group conducts a quarterly review of restraint data, she said.
"In general, it is a small group of the same clients who are restrained," she wrote in an email, noting that some clients have "complex behavioral and mental health issues."
Nationwide, restraint remains "ingrained in the environment" at many sites, said Deborah M. Kennedy, a vice president and head of the abuse investigation unit at Chicago-based disability advocacy group Equip for Equality. She added that initiatives to reduce its use often incur pushback, sometimes out of care workers' fear of losing a tool in the "toolbox."
"Provider settings don't take the time and the effort that needs to be undertaken to make that switch in the culture of the institution," she said, which moves "staff away from looking at individuals in terms of 'You are trouble, you are a problem,' to 'How can I help you?'"
Ellen Blair, a clinician who studied methods of reducing restraint use in psychiatric care settings, said the goal in almost any setting should be to curtail restraint use as much as possible. People who have been restrained often describe it as psychologically traumatic, she said.
When restraints are used, facilities should "drill down" on what happened and conduct a formal debriefing with staff members, clinicians and others, including incorporating feedback from the person who was restrained, she said.
"I think we all have to strive for zero, and treat every [use of restraints] as a very important incident," said Blair, the director of nursing at Hartford HealthCare Institute of Living in Connecticut.
CRIMINAL CONVICTIONS
Since the beginning of 2019, records show restraint use was involved in three incidents that led to criminal convictions for staff members of the Booneville and Conway centers. Three people were sentenced to probation, and at least two were fined.
That included the episode that broke a resident's arm at Booneville. The staff member later pleaded guilty to second-degree felony battery.
Roughly six months earlier, a Booneville resident lost consciousness when a staff member placed the client with an intellectual disability and schizophrenia in a "choke hold," according to a report. Red marks were visible on the client's neck and shoulders.
In a separate incident at Conway last September, an inspector wrote that video showed a staff member "kicks [Client No. 1] in the back then continues dragging the client, on his back, by his arm and shirt, on the floor backwards," before strapping the client to a papoose board, a report said.
Another staff member who was present at the time didn't move to intervene. Neither of the two present appeared to follow protocols outlined in the client's "safety plan" when he became agitated, a report said.
"To aid calming ask [the client] to take deep breaths and 'Breathe like Luther'. Luther is a horse he used to ride," that plan said.
In addition to prosecutions of staff members involved, the Conway and Booneville centers responded to those and other incidents by taking several measures outlined in written plans, including retraining, checking other clients for harm and monitoring other staff members.
All the incidents discussed in this report were documented through a complaint process. But two of the three that led to criminal convictions may not otherwise have appeared in state data because a mechanical restraint was not used.
Stone, the Division of Developmental Disabilities Services chief, said the agency will work to establish new tracking and metrics for personal restraint use. Those "should be" tracked, she wrote in an email.
"We believe that tracking personal restraint usage, and tracking when that usage leads to a mechanical restraint will be helpful to provide us an overall picture of restraint episodes," she said in her Friday letter to Masseau.
The Chicago investigator, Kennedy, said facilities that don't document those types of restraints "don't have any control" over how they're used. A physical hold "can be as dangerous" as a mechanical restraint, she said.
Documents on restraint use also demonstrate the stakes when advocates and family can't visit people in long-term care facilities, as was true earlier in the pandemic.
Some limited visits to the human development centers have resumed. Experts in long-term care say contact with family members plays an important role in safeguarding residents.
Limited interaction with the public is part of a problem with institutional care more broadly, said Serena Lowe, interim executive director of Washington, D.C.-based TASH, a disability-rights advocacy group.
Clients who live in institutions are "really in a very segregated existence. That's where abuse happens, when nobody's looking," she said.
Information for this article was contributed by Eric Besson of the Arkansas Democrat-Gazette.