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Health risks, restraint, and
alleged abuse in New Jersey programs for children and adults with developmental
disabilities.
Jamie Ruppmann
Director Governmental relations
TASH: Equity, Opportunity, and Inclusion for People with Disabilities Since 1975
29 West Susquehanna Avenue, Suite 210
Baltimore, MD 21204
jruppmann@tash.org
410-828-8274 x 104
www.tash.org
The New Jersey Department of Human Services, Division of Developmental
Disabilities, has just released the Bancroft NeuroHealth Survey Report of April
2002. Bancroft NeuroHealth in Haddonfield, New Jersey is licensed as a Private
Residential Facility (PRF) for individuals with developmental disabilities and
currently serves 66 children from in-state and out-of-state. Among DHS's
voluminous findings are the following:
"SUMMARY: The facility is currently in substantial noncompliance with NJAC
10:47, Standards for Private Licensed Facilities for the Developmentally
Disabled. The citations noted in this survey are multiple and related to:
* The violation of the individuals' rights;
* A direct risk to the individuals' mental and physical health;
* Physical plant standards throughout the facility."
"There was no documentation available in the Behavior Management Manual to
indicate that rules of conduct to promote individual growth actually incorporate
procedures for reinforcement of positive behaviors. In addition, the majority of
Bancroft's Intervention Plans did not include techniques for replacing
maladaptive behavior with an adaptive (appropriate) behavior."
"The annual fire inspection was conducted on December 27 and 28, 2001...At
that time, per Bancroft staff, one hundred and fifty (150) violations were
noted."
"None of the persons identified as psychologists in the Private Residential
Facility are currently licensed in New Jersey."
"The review of records revealed that the agency continues to employ at
least one employee whom they have found guilty of abuse."
"The governing body has not ensured that the facility is maintained,
staffed, and equipped in such a manner as to effectively implement the programs
of the facility."
"The governing body did not consult with the licensing or inspecting agency
prior to making any substantial alteration to the program description."
"There was no evidence that the nursing staff received clinical supervision
from the time that the Director of Pediatric Nursing was assigned to the
outpatient department, in February of 1999 through September of 2001."
Among evidence noted is "The poor quality of the nurses' progress
notes"; "The implementation of medication protocol, developed by
behaviorists, who have no medical background, and prescribe poor clinical
nursing technique"; "medication errors"; and "Poor or absent
documentation of clinical nursing assessment and follow-up care even when the
progress note states 'will monitor.'"
The report includes extensive examples of medication errors, medications missed,
a failure to notify the physician in these cases, and "repackaging
medications." Among the citations for the Lindens (described as a
"Neurobehavioral Stabilization Unit") are: "Verbal orders were
not always signed by physicians to reflect confirmation"; directions on
medication were "not consistent with the physician's orders" or
"did not reflect dose change"; and "recapped needles" were
found.
"In the Lindens, the protocols often include aversive techniques that are
not compatible with the individuals' behavior intervention plan(s), or other
individual protocols or treatment plan(s). Such aversive techniques include:
* meal modification
* aversive stimuli (water mist or lemon squirt)
* forced compliance (without specifying Level II or Level III)
* emergency personal restraint without indication the level of aversiveness.
The protocols do not routinely indicate the name of the author, the necessary
approvals, or the date of implementation. The protocols frequently use terms not
defined in the agency's approved Behavior Management Manual......There was no
documentation that described what was actually implemented and the individual's
response."
"None of the numerous Tables of Organization submitted during the
inspection accurately reflect the current structure of the organization as
described by (name blacked out) 3/28/02."
"The agency has not demonstrated compliance with the internal procedures
for reporting and investigating both Internal Incidents (IR) and Unusual
Incidents (UIR)."
"Agency staff were not able to describe procedures which they routinely
implement, for example: Medical Emergencies, Unusual Incident Reporting and
Investigating, Individual Rights, and Habilitation."
On the conference room bulletin board of the Lindens was posted an
"untitled document" describing "Protective Holds" such as
basket holds, and asserting that "they do not meet the definition of a
restraint and do not require orders or LIP face to face assessment."
"Many incidents found in the progress notes in the individuals files were
not reported as Incident Reports (IRs) or Unusual Incident Reports (UIRs).....Medical
Incident Reports are maintained in a single binder, by date rather than by
individual served, in the Health Office. They are not part of the individual's
record. The data are not forwarded to administrative or executive staff. There
is no procedure or requirement for these documents."
"The Procedures for the Internal Investigation of Incidents, found in the
General Bancroft Policy and Procedure Manual and the Lindens Manual, are not
internally consistent as related to responsibilities and time frames.
Additionally, neither of the Policies and Procedures is followed."
"It is routine practice in the Lindens to perform body checks on each shift
without clinical indications. This is a violation of the individuals' right to
privacy. Further, when injuries are noted, there is frequently no follow-up to
determine the source. Unexplained injuries are not documented as per the
agency's Incident Reporting Procedure."
Although "Seclusion and isolation (the placement of an individual in a
locked room) is prohibited," a "seclusion room" with an outside
lock was identified; there was no way for the door to be opened from the inside.
"A complete record for any individual was not available. Additionally, a
copy of the current IHP, including progress notes for each discipline, was not
available to staff working with the individual."
"The nurses have received training neither in UAP (University Affiliated
Programs Training) not in agency internal policies and procedures relating to
medication administration."
"Nursing notes are often fragmented, with little or no nursing assessment,
and lack documented proper follow-up to care." Examples are cited of
failures to follow through on discussion of medications with parents, or to
comply with parents' requests re medications.
"The use of psychoactive medications, in the absence of a psychiatric
diagnosis, are not incorporated into the individuals' IHP/treatment plans."
"In both the Lindens and the Pediatric and Adolescent Campus, the list of
current diagnoses was not maintained. The diagnoses are not updated when they
are changed by either the consultant physicians or advanced practice nurses.
Further, the consultants, from the same office, are not internally consistent in
the DSM IV-R diagnosis for particular individuals."
"Major changes are made to (name blacked out) IHP without input, review,and
approved by the interdisciplinary team."
There are numerous citations of staff's failure to receive training,
orientation, and reference checks. "The Behavioral Psychologists, in their
interviews, stated they have not been trained in or provided access to the
Division Circulars which regulate Behavior Management and Crisis
Intervention." There are citations for uncertified "Clinical
Associates," one a former "merchandiser for Pepsi-Cola and driver's
helper for New England Retain Express," of an unlicensed Social Worker,
Behavioral Psychologists without NJ licenses, and nurses without
"documentation of their current nursing licenses." Also, "Job
descriptions in the files were not consistent with the annual reviews, goals,
and development plans for staff in either residential program."
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