Report finds ‘law of silence’ in mental health facility where employees were abused and patients neglected – ProPublica


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Several employees at the Choate Mental Health and Developmental Center attempted to cover up a brutal attack on a patient, according to a new report from the Office of Monitoring within the Illinois Department of Human Services.

The IDHS report said the “widespread cover-up attempt” about that incident referred to a “law of silence” deeply entrenched among some workers.

The Office of the Inspector General Report It follows a series of stories by Capitol News Illinois, Lee Enterprises Midwest, and ProPublica that reveal a Patient abuse culture And the Cover-ups in a state-run facility in rural southern Illinois that serves people with developmental disabilities, mental illness, or a range of disorders. News organizations reported details of the December 2014 beating of Blaine Richard and employees’ attempts to conceal the abuses; The series also showed how workers accused of allegations of abuse rarely face serious consequences for their actions.

The SIGIR report, which comes nearly eight years after the attack on Richard, reiterated many of the findings of news organizations and called on IDHS to do more to protect patient safety. News organizations requested the report when it was completed in September under the Illinois Freedom of Information Act, but the request was denied until this month.

Among the most egregious abuses, an OIG investigation found that mental health technician Mark Allen held Richard in a chokehold and repeatedly punched him in the face after the two argued, leaving the patient with black eyes, a broken lip, and bruises to his face and upper body. In addition, the OIG cited five mental health technologists for negligence after they witnessed abuse but did not seek medical attention for the patient or report the abuse to authorities, despite the fact that one later told authorities that Richard appeared to be “gone.” Three rounds with Mike Tyson.”

But the OIG’s investigation showed that the problem was not limited to a few bad actors. Among the challenges faced by investigators when called to the scene: A mental health technician initially lied to state police and said he was in the bathroom at the time of the assault. A housekeeper told them she had not seen any blood in Richard’s room but later admitted its presence. A social worker who was romantically involved with Allen leaked information about the investigation. The SIGIR report stated that a nurse and a doctor had made misleading statements about the extent of Richard’s injuries.

This complicity prompted the Inspector General to neglect Schott himself. The Office of the Inspector General said the facility should take responsibility for “failing to prevent a culture in which many employees choose to protect fellow employees rather than an individual who is being abused and who appears to feel comfortable doing so”.

The SIGIR report concluded that “so many employees have been involved in covering up the abuse of [the patient] It suggests that this type of behavior may be endemic to Choate.” Previous reports from news organizations have revealed credible allegations of abuse in which the state’s attorney declined to press charges because he said staff would not cooperate in determining what happened.

An excerpt from the “Recommendations” section of the Illinois Department of Human Services Inspector General’s report calling for employees who obstruct investigations to be held accountable.


attributed to him:
Source: OIG report obtained by Capitol News Illinois

The OIG report stated that it was “critically important” that when employees lie or withhold information in an investigation, they “face consequences for their actions” — and that one of the best ways to identify such plots is to use video footage. The agency recommended installing indoor security cameras at Choate to break the code of silence “from the start”.

In Richard’s case, more than a year passed before anyone was arrested in connection with the beating. In 2016, Allen was charged with felony and intimidation, and three others – Kurt Ellis, Eric Beetle and Justin Butler – were charged with felony obstruction of justice. All plea deals were eventually accepted with reduced charges: Allen was convicted of the felony of obstructing justice for lying to the police, and the others were convicted of failing to report the abuse, which is a misdemeanor.

But no one has been held criminally responsible for Richard’s mistreatment and no one has served a prison sentence.

News agency reports also showed that Allen continued to be paid for a full year after the attack, until he was charged with a criminal offense. A ministry spokesman said he has since been suspended without pay and resigned in early October.

But the other three never missed government salaries until they were suspended pending termination last week in the wake of an Inspector General’s Office report that found them neglected. The state, collectively, has paid them more than $1 million since Richard’s attack. At first, they were assigned tasks away from the sick, such as tending the garden, cooking, and washing; Later, they were sent home on administrative leave.

In addition to OIG’s findings against those facing criminal charges, the report cited two other negligent employees—Christopher Lingle and John “Mike” Dickerson; The report concluded that the two parties witnessed the violation and did not intervene or report it. Lingle continued to work until earlier this year and is now suspended without pay. Dickerson worked at the facility until he retired in 2017. In his last three years on the job, he mowed the lawn at Choate.

In a statement, IDHS spokeswoman Marisa Colias said all of the employees named in the report either resigned or were suspended pending layoffs after the SIGIR investigation concluded in September. It has previously said that IDHS cannot take disciplinary action against employees until the OIG case is concluded. That investigation has been delayed for eight years pending the resolution of Allen’s court case, which ended last December.

Allen could not be reached for comment. The union spokesperson representing the other employees mentioned in the case did not respond to an email requesting information about their employment status. When reporters contacted them to get Previous article about the accidentButler, Beetle, Ellis and Dickerson did not respond to requests for comment. Lingle, who was not named in the previous story, did not respond to a message sent via Facebook this week.

Kolias also said that in the eight years since the case began, “additional safeguards have been put in place to protect residents, patients and staff from harm.” These changes include bringing in Equip for Equality, a legal defense organization, to monitor conditions within the unit, setting up training on reporting abuse and neglect, beefing up security and Choate’s professional staff and installing security cameras — something the IGO has. Called more than 20 times over the past five years. (This week, an IDHS spokesperson said the department has 39 cameras and plans to begin installing them this month.)

Although the OIG called for more serious consequences for employees who obstruct abuse investigations, the report stopped short of issuing more serious findings against mental health professionals that would have prevented these employees from seeking employment in various health care settings such as a hospital and nursing homes for the elderly. Or a veteran’s home.

State law requires that the Office of the Inspector General report the names of any employees cited for abuse or “egregious negligence” to Health Care Workers Registry of the Illinois Department of Public Health. Under this law, Allen will be reported to the registry but the others will not.

The fact that these workers are not barred from working in the future with vulnerable populations is “extremely worrying,” said Stacey Asheiman, vice president at Equip for Equality. Peter Neumer, IDHS Inspector General, said it was the general policy of his office not to comment on specifics of his investigations or his decision-making process.

It is clear from the report that OIG feels constrained by the current regulatory language, Attorney Acehmann said. The report stated that the behavior of workers who witnessed the abuse was “extremely concerning” but did not fit the legal definition of “atrocious” because Allen, and not the other technicians, is directly responsible for the injuries, and because the other technicians. Failure to report the assault did not lead to the patient’s death or a serious deterioration in his physical condition.

Although he declined to comment directly on the case, Neumer indicated that legislative action may be needed. He said the AUD stands ready to cooperate and advocate policy changes to further deter employees from engaging in “symbol of silence” behavior. “

Ashman was more outspoken, saying that Illinois lawmakers should address shortcomings in laws governing standards of behavior for direct care workers.

“It is clear that the laws need to be updated to impose stronger penalties for this misconduct and to ensure that employees who turn a blind eye to the welfare of people who are paid to assist them are reported to the Illinois Health Care Workers Registry because they are ineligible to work in health care facilities.”

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