DLC Issues Report Announcing Results of Its Investigation of Patient Deaths at Arbour Health Systems Hospitals

Arbour Health Systems
BOSTON, February 13, 2018 – The Disability Law Center (DLC) issues a Report today announcing the results of its abuse and neglect investigation into patient deaths that occurred in psychiatric hospitals operated by Arbour Health Hospitals, Westwood Lodge (currently closed) and Pembroke Hospital. Westwood Lodge was an 89 bed facility serving children, adolescents and adults. Pembroke Hospital is a 120 bed facility serving adults, adolescents and older adults. The Department of Mental Health licenses inpatient psychiatric facilities operated by Arbour Health Systems.

Dan Smith (a pseudonym), a 32 year old man, died on April 25, 2015, after being at Westwood Lodge for a period of 16 days. Mary Jones (a pseudonym), a 20 year old woman, died on August 30, 2015, after being at Pembroke Hospital for a period of 2 days. DLC analyzed whether these individuals were subject to abuse or neglect in connection with their hospital stays or their deaths. Based upon an extensive review and analysis of relevant documents and primary investigations, DLC finds that both of these individuals had been subject to neglect while each of them had been a patient at their respective facilities. In addition, Westwood Lodge abused Mr. Smith when it administered a medication restraint in violation of state regulations

In conducting these investigations DLC’s found disturbing similarities between both the presentation and needs of the individual victims, and the presence of the same failures that resulted or may have resulted in the deaths of these individuals. These common concerns may evidence a broader systemic problem at Arbour Heath Systems. For example:

  • Arbour Health Systems failed to ensure that observation rounds are conducted in a manner consistent with the hospitals’ own policy; and
  • Arbour Health Systems failed to ensure that timely and effective communication between the direct care, nursing, and psychiatric staff occurred and that information was incorporated into the patients’ individualized treatment plan.

Other problems found by DLC in its investigation include the following:

  • Arbour Health Systems failed to ensure that prior to starting a new medication regimen, all risks and benefits associated with both the proposed medication, including all potential drug-drug interactions, and all medications taken on or before admission, are fully discussed with the patient.
  • Arbour Health Systems failed to ensure that upon admission the patient received routine and preventative medical treatment.
  • Arbour Health Systems failed to develop individualized treatment plans that capture all pertinent information and data regarding the patient’s recent history, including, but not limited to, age, medical status, vital signs, recently prescribed medications, current diagnosis, suicidal and homicidal behaviors, self-injurious behaviors, risk assessments, medical history, substance abuse and trauma history.
  • Arbour Heath Systems failed to allow up to 72 hours for the psychiatric and medical staff to assess, diagnose, and develop a written, individualized treatment plan, including the provision of       a “wash out” period to the patient prior to starting that patient on new medication.
  • Arbour Health Systems failed to ensure that the patients were competent and had the capacity to provide Specific and Informed Consent before being administered psychiatric medication.
  • Arbour Health Systems failed to ensure that all life-saving equipment is inspected and serviced on a regular basis to ensure that the equipment is in proper working order and is easily located when needed.

DLC seeks a detailed and effective remedial plan Arbour Health Systems to remedy the problems identified in its Report. Included in such a remedial plan would be changing policies and practices to ensure that the critical lessons learned from these tragic deaths are never repeated in the future.

DLC, as the designated Protection and Advocacy System for Massachusetts, is authorized under federal law to investigate incidents of abuse and neglect of individuals with disabilities. The investigation was conducted and the report was written by Walter Noons, Senior Staff Attorney and Stanley J. Eichner, Litigation Director.

Read the Report

Contact: Stanley J. Eichner, Litigation Director

617-723-8455

seichner@dlc-ma.org

DLC Finds Abuse & Neglect at Kindergarten Center in Haverhill

Crowell School

BOSTON, February 1, 2018 – The Disability Law Center (DLC) issues a Report today announcing the results of its abuse and neglect investigation at the Crowell Kindergarten Center (Crowell) in Haverhill, Massachusetts. Crowell is a public school within the Haverhill Public Schools, serving 150 kindergarteners with and without disabilities.

During the winter of 2017, DLC received complaints regarding the treatment of students with disabilities at Crowell. As part of its investigation, DLC interviewed 20 parents and reviewed records for seven students with disabilities. DLC also reviewed school records, conducted a site visit and interviewed Crowell’s principal and two staff members.

DLC’s investigation found Crowell engaged in abuse by violating multiple state and federal laws regarding the use of restraint, time-out and disciplinary exclusions. DLC also found Crowell neglected students with disabilities by failing to develop or implement legally mandated policies, trainings and social/emotional/behavioral services for students with disabilities. For example:

  • Crowell repeatedly overused restraints on at least one five-year old student with disabilities. These restraints were not reviewed and no formal behavioral interventions were attempted in an effort to curb the frequent restraints.
  • Crowell failed to properly report other student restraints.
  • Crowell forcibly contained students for crying and acting up in cubby closets with gym mats for purposes of punishment and detainment, instead of calming.
  • Crowell frequently misused exclusionary time-out as punishment, removing students from class for extended portions of the school day, even after students had calmed down.
  • Crowell used informal illegal exclusions instead of comprehensive behavior management tools.
  • Crowell did not provide inclusion students with any direct special education services, in violation of many students’ IEPs.

“The pattern and practice of forcibly containing and restraining very small children with disabilities repeatedly for common kindergarten misbehavior is extremely troubling.” says Christine Griffin, DLC’s Executive Director. “This treatment not only hurts these young students in the short-term, but causes long-term trauma for them and possibly all the children in these classrooms.”

DLC seeks a remedial plan from Crowell with 45 days to address improved policies, procedures, trainings, as well as increased access to adequately trained staff and social/emotional support services.

DLC, as the designated Protection and Advocacy System for Massachusetts, is authorized under federal law to investigate incidents of abuse and neglect of individuals with disabilities. The investigation was conducted and the report was written by Colleen Shea, Attorney/Skadden Fellow and Stanley J. Eichner, Litigation Director.

Read the Crowell Investigation Report

Contact: Stanley J. Eichner, Litigation Director

617-723-8455 x153

seichner@dlc-ma.org

 

Experts hail Bridgewater State Hospital reforms at CRJ panel discussion – Community Resources for Justice

In the past nine months, the drumbeat of criticism from disability rights activists has morphed into accolades for Gov. Charlie Baker, who instituted sweeping reforms at the Department of Corrections-run Bridgewater State Hospital, and Correct Care Solutions, the Tennessee company brought in to oversee care of patients there.

Source: Experts hail Bridgewater State Hospital reforms at CRJ panel discussion – Community Resources for Justice

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