Problems with abuse, neglect and cover-ups at Choate extend to other
developmental centers in Illinois
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[July 12, 2023]
By MOLLY PARKER
Lee Enterprises Midwest
& BETH HUNDSDORFER
Capitol News Illinois
This year, Illinois officials announced what seemed like a solution to
the outcry over abuse and cover-ups at a state-run developmental center:
Downsize the facility and move about half the residents elsewhere. Some
of the roughly 120 relocated residents of the Choate Mental Health and
Developmental Center would receive care in community settings. Others
are expected to end up in one of the six developmental centers located
in other parts of the state.
Gov. J.B. Pritzker and Illinois Department of Human Services Secretary
Grace Hou said the plan would “reshape the way the state approaches care
for individuals with intellectual and developmental disabilities.”
But a new investigation by Lee Enterprises Midwest, Capitol News
Illinois and ProPublica has found that the problems at Choate extend to
the other centers as well. People with developmental disabilities living
in Illinois’ publicly run institutions have been punched, slapped, hosed
down, thrown about and dragged across rooms; in other cases, staff
failures contributed to patient harm and death, state police and
internal investigative records show.
The Illinois State Police division that looks into alleged criminal
wrongdoing by state employees investigates more allegations against
workers at these seven residential centers than it does at any other
department’s workplaces, including state prisons, which house far more
people, according to an analysis of state police data.
It has opened 200 investigations into employee misconduct at these
developmental centers since 2012 — most of them outside of Choate.
The state’s seven developmental centers, home to about 1,600 people, are
situated from the bottom of the state at the edge of the Shawnee
National Forest all the way north to the Wisconsin border. The oldest
operating facility opened in 1873 and the newest one in 1987. They house
dozens, and in some cases hundreds, of people with developmental
disabilities in a hospital-like setting. These residents have a range of
conditions: genetic, acquired from a problematic birth, or resulting
from exposure to dangerous chemicals or from injury in childhood or
adolescence.
As in other states, many of these facilities were built in small towns
and rural areas. Today, they are short-staffed and at times chaotic and
dangerous, according to a slew of reports and interviews with workers
and advocates. This May, the safety concerns inside the developmental
centers prompted a court-appointed monitor to urge IDHS to stop placing
anyone covered by an expansive consent decree into any of the agency's
developmental centers.
“Too many residents suffer physical injury, sexual assault and death to
regard placement in such facilities as safe,” wrote Ronnie Cohn, the
monitor and a New-York based expert on disability services, in a report
that was prepared at the behest of a federal judge in ongoing
proceedings.
Illinois is a stubborn outlier among states, continuing to funnel huge
sums of money into institutional care. Many others have entirely
shuttered or significantly downsized their state-run institutions.
Illinois has about the same number of people living in them as do
California, Florida, New York and Ohio combined. In Illinois, the
lawsuit that led to the 2011 consent decree argued that the state had
violated the civil rights of people with developmental disabilities by
failing to offer enough options for community-based care. The next year,
the state closed one of its centers and tried to shut another; that
effort, to shutter the Murray Developmental Center in southern Illinois,
failed in the face of union and community pushback. Now, the state is
making space for 60 more residents at Murray, some of which will likely
transfer from Choate.
“This is one of the most backwards states in the nation on everything we
know how to measure when it comes to the care of people with
developmental disabilities,” said Allan Bergman, a consultant from
suburban Chicago who advises clients and governments across the U.S. on
disability policies and programs.
We asked IDHS about the new reporting on issues within the state’s
developmental centers. Agency spokesperson Marisa Kollias pointed out
that the state had announced a broader review of every facility that
IDHS operates as part of its response to the reporting on Choate. She
said in a statement that the state has worked to “identify the root
causes of misconduct” and correct them. Among recent improvements, IDHS
has appointed a new chief safety officer, held numerous trainings on how
to report abuse and neglect and ordered more than 400 security cameras
for installation across all of its facilities by the end of the year,
she said.
Additionally, IDHS acknowledged shortcomings in the community care
settings that operate under the agency’s oversight. Kollias said that
the community system had been financially neglected by the prior
administration and noted that Pritzker’s administration has successfully
advocated for millions of dollars in new spending for these programs.
Funding for home- and community-based care has roughly doubled what it
was when Pritzker took office to more than $1.7 billion, though
advocates contend it’s still not enough after years of steep cuts.
State Police Investigations Rise
State police investigations of claims against staff at Illinois’
developmental centers are on the rise: Nearly 70% of them over the past
decade were initiated since 2019, the year Pritzker took office.
Of the 200 state police investigations into employee misconduct over the
past decade, 161 pertained to allegations of physical abuse and criminal
battery; 25 to allegations of sexual assault and custodial sexual
misconduct; and 10 to alleged criminal neglect of residents. Four were
death investigations.
Of those cases, 22 led to convictions, almost all of them for abuse.
A spokesperson for the state police said the agency could not speak to
the reasons for the increase or for the disparity in the volume of cases
from IDHS facilities that it handled in recent years as compared with
Illinois Department of Corrections prisons or other agency workplaces.
But Kollias, the IDHS spokesperson, said the department views the
increase in state police investigations “as an improvement in
accountability at the facilities.” She also noted that most cases did
not lead to convictions.
Both the numbers and interviews show how difficult it is to pursue
charges, even when investigations get underway. In the facilities
outside of Choate, between 50% and 99% of residents have disabilities
that are diagnosed as “severe and profound”; some of those individuals
are nonverbal and unable to communicate in traditional ways.
Investigative records show instances of employees failing to report
abuse or working together to hide it, or a general reluctance on the
part of state employees to share information with investigators. Even
when there’s a conviction, state police investigators are not always
able to fully determine what happened.
For instance, among the more recent physical abuse cases where a
conviction was secured is one from Shapiro Developmental Center in
Kankakee, a small industrial city on the outskirts of suburban Chicago.
In 2020, a patient was found with U-shaped markings and dark bruising on
his chest, back, arms, legs and genitals.
A nurse examined his injuries but dismissed them as a rash from
medication. A physician who examined him the next day had a different
take: She believed the markings were consistent with someone striking
the patient with an object, such as a belt or cord. The U-shaped
markings looked like they could have been from a belt buckle, she told
investigators.
Police interviewed multiple employees who worked the night shift, but
they offered little information. The patient was unable to provide
police specific details of the incident. He was only able to tell them a
female worker “beat the hell” out of him on the night shift by striking
his genitals with an unknown object.
The patient’s treatment plan notes that he needs help managing behaviors
that include irritability, agitation and outbursts. One employee
admitted to police that she had slapped the patient across the face that
evening after she had directed the patient to stop a problematic
behavior and he told her to “shut up, bitch.” But the worker denied she
was responsible for any of his more serious injuries. No one else came
forward with any information.
The worker pleaded guilty last year to misdemeanor battery and received
12 months of court supervision. She was fired from Shapiro, but neither
state police nor IDHS’ inspector general were able to determine the
cause of the patient’s more extensive injuries.
Peter Neumer, the IDHS inspector general, said his department regularly
encounters cover-ups at facilities across the state, which prompted him
to push for a new legal measure enhancing the penalty options against
those who attempt to stonewall or obfuscate investigators. Pritzker
recently signed it into law.
The state police reports are not the only cause for concern. The
inspector general receives and investigates all allegations of resident
abuse and neglect. Some of those result in recommendations for civil
penalties against employees, up to termination, and suggestions to
address systemic failures. The most serious cases, where criminal
misconduct is alleged, are also passed on to the state police.
Between 2013 and 2022, the inspector general investigated nearly 4,000
allegations from the developmental centers — with the most recent five
years seeing a 45% increase in allegations compared with the earlier
part of the decade.
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Credit: Alex Bandoni/ProPublica. Source
Images: Reporters’ notes and the Illinois state government.
There are also safety concerns documented in records from the
Illinois Department of Public Health, which responds to complaints
because it is responsible for ensuring compliance with Medicaid and
Medicare regulations.
These records show that in addition to the abuse cases, residents
have suffered from life-threatening mistakes and oversights by
employees.
At Mabley Developmental Center, in the small north-central Illinois
town of Dixon, a patient drank from a bottle of toilet bowl cleaner.
The inspector general found that a worker had neglected the patient,
who died of cardiac arrest three days later.
At Ludeman Developmental Center in Park Forest, in south suburban
Cook County, a resident who was supposed to be closely supervised
left the facility without permission and was later found walking
barefoot across a busy six-lane street. In a different elopement
case, a Ludeman resident suffered hypothermia after he went outside,
unbeknownst to staff, one early fall morning when the temperature
was in the 30s, wearing only a diaper and sat in the wet grass.
At Kiley Developmental Center in Waukegan, on the Wisconsin border,
staff locked a disruptive patient in his room using a bedsheet tied
across his door, an unauthorized form of restraint, according to
health department inspection records. That same facility
accidentally allowed an employee who the inspector general had
previously found had abused a patient to return to work for two
months before anyone noticed, according to staff interviews with
health department surveyors. The worker has since been fired,
according to a statement from IDHS.
Critical Staffing Shortages
This rise in allegations of violence and neglect comes amid
significant staffing shortages, leading employees to work
unsustainable and potentially dangerous overtime hours, according to
an analysis of overtime records and interviews with more than a
dozen employees at four facilities.
As of February, about 200 employees at developmental centers
statewide — about 5% of the workforce — were unable to perform the
job they were hired for pending the outcomes of abuse and neglect
allegations with the state police or inspector general’s office.
Most of them were on paid leave, including some who had been on paid
leave in excess of two years. Others had been reassigned from their
regular duties, and a small number had been suspended without pay
pending the outcome of criminal court cases against them.
Neumer, the inspector general, said his office has prioritized
working through cases more quickly to reduce the amount of time
employees are out on leave. But in cases involving law enforcement,
the inspector general cannot proceed with its internal investigation
until a criminal case concludes, he said. Some cases linger for
years with state police or prosecutors’ offices.
The staffing issues go well beyond those who are being disciplined.
Across the state, about 570 jobs at developmental centers — more
than 14% of positions — are unfilled.
AFSCME Council 31, the union that represents most workers at these
24/7 facilities, issued a report in December criticizing the state’s
use of forced overtime to address chronic understaffing and raising
alarms about its impacts on workers and residents.
In at least one case at Kiley, staffing shortages may have
contributed to a patient’s death.
In February 2022, an individual with a known swallowing disorder was
supposed to be closely monitored while eating. But on this day, a
worker went home sick, leaving her unit short-staffed. While no one
was watching, the resident choked and died, according to a report by
the Illinois Department of Public Health. A worker told public
health investigators that records were fabricated at a supervisor’s
request to make it look as though the facility had provided proper
supervision.
The inspector general’s investigation into the incident is ongoing,
and the employees who were involved remain on leave. IDHS said in a
statement that in response to the health department’s findings,
Kiley staff received training on “providing sufficient direct care
staff.”
That was the second time in two years that a patient at Kiley with a
known swallowing disorder choked to death while eating unsupervised.
In a 2020 case, according to a report by the inspector general, the
man may have been dead for several hours before anyone noticed and
called for help.
Kollias, the IDHS spokesperson, said that staffing shortages in
health care are a nationwide problem and that the state has taken
steps to more quickly fill positions. Contract staff are filling in
at every center to ensure required staffing levels for each shift
are met, she said.
Conditions Are “Beyond Dire”
In some of those facilities, employees have raised alarms to their
higher-ups, as a security chief at Choate had done before the state
took action to address problems there, email records obtained under
a Freedom of Information Act request to IDHS show.
This January, Matt Comerford, a Mabley employee, sent an email to
Hou, the IDHS secretary, seeking her immediate attention to
conditions he described as “beyond dire.” In his letter, he said
that patient injuries — including black eyes and, in one case, an
open head wound that required 13 staples — could not be accounted
for, and he accused staff, including administrators, of stonewalling
investigators.
“It has become normal for staff to never seem to know anything about
these injuries,” wrote Comerford, the facility’s business
administrator. He concluded his letter by saying that he believed
speaking out put his livelihood at risk. “But the risks of not
speaking out are far too great for me to remain silent.”
Mabley’s clinical services director, Patricia Fazekas, a longtime
employee who resigned in May, wrote about similar concerns in an
“exit” survey obtained by the news organizations.
“The system is broken and they know if they complain they will be
retaliated against,” she said of staff. If one were to visit Mabley,
they would “witness abused and neglected individuals being cared for
by verbally abused and neglected staff.”
In March, James Zarate, an assistant director at Kiley, emailed a
different senior IDHS official, telling her that residents’
well-being was in jeopardy in that facility, as well. Kiley staff,
he wrote, are receiving “little guidance or training” and the
facility is “operating with a shortage of staff which is being
exacerbated by a toxic work culture.” Six other Kiley employees, who
spoke with a reporter on the condition that their names be withheld
because they still work there, similarly expressed that staffing
issues and mismanagement had created a problematic work environment
that put residents and employees at risk of harm.
The department said that the concerns the employees raised in their
emails were passed on to the appropriate oversight bodies, and that
IDHS is “independently investigating the claims and will address
issues fully and appropriately.”
Both Comerford and Zarate, who do not know each other, faced
disciplinary action shortly after sending their emails and
additional complaints to various oversight bodies.
The department said the disciplinary decisions it made against the
employees were unrelated to their emails and complaints. Zarate, a
new hire, was terminated as a “probationary discharge” after six
months on the job. His final performance review said he had failed
to perform his job duties satisfactorily, such as by not ensuring
that staff completed tasks in a timely manner or seeking input from
his superiors. He was specifically admonished because subordinates
had reported to health department surveyors that a staffing crisis
resulted in residents not receiving “active treatment.”
“Mr. Zarate has made this an acceptable response when not meeting
expectations, resulting in a possible IDPH citation,” the
performance review stated.
The department didn’t dispute that staffing challenges exist, but in
a statement to the news organizations, it said such a response was
problematic because “essential services are expected to be provided
to residents despite staffing challenges.”
Zarate declined to speak for this article.
Comerford was placed on paid administrative leave for 10 weeks, then
suspended for 20 days without pay. Paid leave, the department said,
is not punitive. As for the suspension, a disciplinary letter from
the department said Comerford had, among other alleged infractions,
raised his voice and cursed during a meeting and took a call on his
private cellphone. The department said he had, on multiple
occasions, displayed conduct unbecoming of a state employee and
failed to perform job duties in an accurate and timely manner.
In a statement, Comerford said that “a well-worn page of the DHS
Mabley playbook is to discredit and defame those who address
systemic injustices against the most vulnerable population.” He said
that the department had lied about, exaggerated or taken out of
context many of the circumstances that led to the claims against
him. The department said Comerford had the ability to challenge the
discipline and did not do so. “He served his disciplinary time and
has returned to work,” IDHS said in a statement. |