LINCOLN — Eleven staff members at the Beatrice State Developmental Center are accused of abusing disabled residents or failing to report abuse. They face disciplinary action that could cost them their jobs.
An internal investigation by the center found that direct care staff hit, pushed or choked seven residents, said Jodi Fenner, director of the Division of Developmental Disabilities for the Department of Health and Human Services.
The abuse allegations involved five staff members, Fenner said, in multiple incidents dating back to June.
Three additional care staff members knew about the abuse but did not report it, and three supervisors face discipline because the abuse occurred on their watch, Fenner said.
A former employee reported the abuse in early September, which triggered both the internal probe and a criminal investigation by the Nebraska State Patrol.
Fenner described the alleged abuse as systematic and borderline sadistic.
For example, staff members choked more than one resident to the point of passing out, as their co-workers stood by, joking and laughing, she said. So common was the use of headlocks that some staff members referred to them as "choking out" or "rebooting" the residents, using the headlocks as a punishment for bad behavior, according to the investigative report.
"These are just mean and heartless actions if they are in fact true," Fenner told The World-Herald on Wednesday. "This involves the treatment of residents as if they were nonhuman."
The report represents a shocking portrayal that conjures the worst stereotypes of what happens behind the walls of a state institution that has the task of caring for people with severe developmental disabilities.
It also constitutes a serious setback for the Beatrice center at a time when it had taken steps to recover from the 2009 loss of Medicaid funding, the consequence of repeated failures to meet federal care standards.
It remains to be seen whether criminal charges are forthcoming. The State Patrol concluded a two-week investigation last month, and Gage County Attorney Roger Harris has been reviewing it before making a decision on possible prosecution.
Omaha State Sen. Steve Lathrop, who heads a special legislative committee focused on issues at the center, said Wednesday night that after all of the attention on eradicating abuse at the institution, it's hard to believe the problem would resurface. He recalled a 2008 investigation by the U.S. Department of Justice that found a pattern of abuse at the center.
"It has overtures that are familiar to us, and I believed it was behind us," he said. "I'm very disappointed that it's happened again."
The report has been given to members of the legislative committee, which has a meeting scheduled for Friday.
All the abuse occurred at a unit known as Ward 106 Kennedy, Fenner said. Although some of the residents suffered injuries and bruises, none was hospitalized.
Several of the residents targeted by the abuse cannot talk or communicate well.
All residents of Ward 106 Kennedy have since been transferred to other units on campus, and the ward has been shut down.
The names of residents and staff were removed from a copy of the 78-page report provided to The World-Herald. The document showed that investigators interviewed 32 staff members and several residents.
Past investigations have identified mandated overtime as a contributor to problems at the center. Fenner stressed that the incidents could not be characterized as isolated outbursts triggered by the stress of working with people who have serious mental, medical and behavioral problems.
"It's disturbing," Fenner said. "It's hard to read the report and not get emotional."
The accused staff have been on suspension since early September, Fenner said. They will be served Thursday with "notices of allegations," which she called the first step in a process that will lead to firings if the report findings are upheld.
Those accused will be given opportunities to challenge the personnel action.
All 16 staff members who worked the same shift at Ward 106 Kennedy have been suspended. Five of the 16 were not accused of wrongdoing at the end of the investigation.
The institution has a zero-tolerance policy regarding the abuse or neglect of residents. The policy also holds staff members responsible if they fail to report abuse, a point repeatedly highlighted in regular training, Fenner said.
State law also requires any employee to report suspected abuse.
Fenner was especially disheartened by the fact that some staff members, while they did not participate in the abuse, failed to report it.
"There is no excuse for it," she said. "Such blatant disregard to human dignity, you can't chalk up to being tired. Profound, intentional acts of abuse that you then laugh and joke about? That's not staff being tired."
The independent investigator who works at the center prepared the internal report that documented the abuse. The investigator, who is not supervised by any Beatrice administrators, sat in on the interviews conducted by the patrol, Fenner said.
She decided to act on the internal report without waiting for the county attorney's decision for two reasons. First, it is important to start the personnel process so the uncertainty over staffing can be resolved.
In addition, she said, rumors were rampant in Beatrice, and she concluded that it was necessary to make as many facts known as possible.
She stressed that the allegations involve a small number of staff members who worked closely together during the day shift. Some have worked at the center as long as 22 years, while others are recent hires.
The center employs about 600 staff members and provides care for 150 people with developmental disabilities.
Fenner expressed concern that the investigation's findings will overshadow the excellent care delivered by most of the center's staff. She called it one of the world's most challenging but rewarding jobs.
Indeed, many families of the Beatrice center residents have been quick to defend the center.
Shortly before the allegations arose, state officials had completed work to regain Medicaid certification — and funding — for three of the five units at the center.
After the Beatrice center lost Medicaid funding in September 2009, state support for the facility had to be increased by $40 million for the 2009-11 budget period.
State officials divided the center into five affiliated units last year to improve care and regain certification. Federal inspectors had made the first of two visits to the fourth unit required before being recertified.
State officials had soon planned to ask for an inspection of the fifth unit — Kennedy.
Contact the writer:
402-473-9587, joe.duggan@owh.com
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