The disAbility Law Center of Virginia has brought to light a troubling trend of fatalities under the supervision of licensed care providers for individuals with intellectual disabilities. Their recent report scrutinizes 181 deaths, revealing alarming instances where basic emergency protocols were neglected.
Among the findings, the report highlights several cases where caregivers failed to administer lifesaving CPR or contact emergency services in a timely manner. Notably, 14 individuals on food safety plans succumbed to choking, despite the risks being well-documented. In some instances, caregivers knowingly provided unsafe foods to the residents, leading to tragic outcomes.
These incidents have predominantly resulted in corrective action plans from the state, yet accountability remains a significant concern. One provider, even after experiencing two choking deaths in her care, managed to find employment with another agency between the incidents, citing her dedication to caring for the disabled.
The report underscores a “pattern of neglect and lack of accountability,” according to the disAbility Law Center. Individuals with intellectual and developmental disabilities (IDD) frequently reside in group homes, where they are promised comprehensive care overseen by the Department of Behavioral Health and Development Services (DBHDS). The state agency funds care for approximately 18,000 individuals through Medicaid waivers.
“The findings of this report highlight critical and alarming deficiencies in the care provided to IDD people receiving DBHDS-licensed services, particularly in relation to emergency medical responses, cause of death documentation, and food safety protocols,” stated the report.
Lauren Cunningham, representing DBHDS, acknowledged the gravity of the findings and expressed appreciation for the disAbility Law Center’s collaborative efforts. “We have implemented a number of activities to address the findings, and we are planning to update our licensing regulations to address further issues,” she confirmed.
Colleen Miller, Executive Director of the disAbility Law Center, initiated the investigation upon noticing irregularities in death certificates, where intellectual disability was sometimes erroneously listed as a cause of death. This led to a thorough examination of sudden and unexpected death reports, with access to confidential investigation records by law.
The investigation disclosed 46 cases where CPR was not performed, and 33 instances of delayed emergency response. Some staff lacked CPR training, while others hesitated to act, believing the situation to be beyond hope.
The choking deaths were particularly egregious, as they involved known dietary restrictions. In a few instances, caregivers intentionally provided dangerous foods to their patients. “It’s awful. Just awful,” Miller remarked.
While Miller is optimistic about regulatory reforms, she advocates for more stringent responses when caregivers jeopardize their patients’ lives. Currently, enforcement primarily consists of corrective action plans. However, the DBHDS can revoke or suspend licenses and refer severe abuse cases for criminal charges.
Cunningham did not comment on whether any providers involved in preventable deaths faced criminal referrals. She emphasized the agency’s commitment to taking “progressive action” for serious noncompliance, including increased oversight through site visits.
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