San Antonio Express-News: Metro and State
Deaths of mentally retarded while bound cause concern
Sunday, October 21, 2000
By Karisa King
Express-News Staff Writer
Diane Harris was splayed across the floor, crying for help and gulping for
air.Pinned under the force of five mental-health aides, her arms pulled
tight across her chest, the 17-year-old thrashed frantically to free
herself. With her dying breaths, she made a desperate plea.
"I can't breathe," she said, as one worker knelt to the floor and pressed
the girl's head between her knees and four others held her chest, arms and
legs.
For the first 10 minutes, the staff at the Seguin Community Living Center
ignored her. One of the workers told her that if she could talk, she could
breathe. Her body suddenly convulsed, then went limp. For good measure, they
continued restraining her for 10 more minutes. She never moved again.
When the girl failed to acknowledge their commands to get up, two workers
propped her rag-doll form into a sitting position on the floor. There she
sat, motionless, her head and neck slumped over her crossed legs, for the
next hour and 40 minutes. The staff dismissed it as a ploy. "It was felt
that she was being manipulative," a nurse wrote in the center's log.
By the time a staff member pushed the girl upright, clear fluid was spilling
from her mouth, her pants were soaked in urine, her lips were blue.
Harris' death, on April 11, 1990, marked the first of at least 18 cases in
Texas over the next decade in which patients died during or soon after being
restrained at residential treatment centers, group homes and facilities for
the mentally retarded and mentally ill.
In the name of preserving the privacy and dignity of the disabled and
mentally ill, state regulatory agencies disclose little if any information
about the circumstances surrounding deaths in which the victims had been
physically restrained.
Through a series of Open Records requests to the Texas Department of Mental
Health and Mental Retardation and the Texas Department of Protective and
Regulatory Services, the San Antonio Express-News obtained documents
identifying deaths that occurred within 24 hours of restraint. The newspaper
then reviewed autopsies, obituaries, law enforcement reports, funeral home
information and news reports to piece together a fuller account of who died
and how.
In violent deaths that often mirrored Harris', mental-health workers
wrestled patients into submission, pressed them face to the floor, squeezed
the air from their lungs, injected them with powerful tranquilizers, wrapped
their necks in choke holds, strapped them with mechanical devices and left
them alone to die. In some cases, the workers made irrevocable mistakes. In
other cases, state investigators concluded that workers broke no rules, yet
patients died just the same.
They choked on their own vomit. They suffocated. Their hearts failed. Like
Randy Steele, 9, and Willie Wright, 14, who died in San Antonio this year,
they were among the state's most vulnerable residents, the mentally ill and
disabled, who died at the hands of people assigned to care for their
well-being.
The patients suffered from schizophrenia, Down syndrome, mental retardation,
drug abuse, depression, behavioral problems.
The records also show that:
a.. Half of the 18 victims were children and teens.
b.. Some families were misled and not told their loved ones died during or
soon after they were restrained by caregivers.
c.. In most cases, patients fought against the restraints, causing scuffles
that sometimes left them with black eyes, bloody noses, scratches and
bruises.
d.. Two of the deaths resulted in criminal charges against workers.
Mental-health professionals view restraints - which include mechanical
devices such as straitjackets, medications and body holds - as appropriate
methods to protect caregivers and their charges.
"This can be a perilous job. You're putting yourself in a position where
you're likely to be attacked," said Anthony Claxton, medical director at
Terrell State Hospital, where a 51-year-old man died in December. "We're
caught between a rock and a hard place. The rates of injury among our staff
are much greater than they are among our clients."
Terrell State Hospital reported 276 injuries to patients over a recent
nine-month period, while employees reported 401 injuries. The hospital
treats about 350 patients a day.
The Texas Department of Health, which licenses psychiatric hospitals, cites
a 1999 state law the agency says prohibits the release of any information
about patient deaths. Before the law took effect, some of the information
was public. The health department would not even confirm, for example, the
March 4 death of Willie Wright, a teen with the mentality of a toddler whose
heart stopped while workers at Southwest Mental Health Center in San Antonio
pressed his head, hips and feet to the floor.
No single set of rules or standard training procedures guides mental-health
workers who use restraints. The regulations are fragmented among a
collection of state, federal and accreditation agencies. No comprehensive
system tracks the number of patients who are injured or die from restraints.
And in Texas, like most states, there is no uniform requirement to report a
death that is restraint-related.
To learn about restraints is to learn about "basketholds" - the equivalent
of a human straitjacket in which patients' arms are tightly crisscrossed
over their chests and held from behind. Experts say basketholds, when
performed incorrectly, can be dangerous because they compress the chest and,
like face-down restraints, make it difficult for workers to see a patient's
face.Attempts to restrain patients can turn into prolonged violent struggles
that strain the body and have medical implications. At a time when a
patient, wild with rage and adrenaline, needs even more oxygen, a bad
physical hold that restricts breathing can be deadly. Researchers have
speculated that the combination of adrenaline and some drugs used to treat
mental illness can trigger a fatal cardiac arrhythmia, or an irregular
heartbeat. A knee wedged into a patient's back can prevent the chest from
expanding and drawing in air.
"Sometimes they're fighting on a full stomach and their abdomen gets
compressed," said Jack Zusman, a Florida psychiatrist and expert on
restraints who has evaluated cases in which workers sat on patients'
stomachs to calm them. "If they're on their backs, they can aspirate" on the
vomit.
The risks posed by the use of such restraints are not new. Mental health
administrators typically start any conversation about restraints by saying
they are to be used only as a last resort.
In practice, however, petty misbehavior has prompted the use of restraints.
Willie Wright didn't want to go to bed. Bobby Randolph, 17, cussed at a
staff member as he protested a search of his room. Diane Harris had a bad
attitude.
In written statements to the Guadalupe County Sheriff's Office, the staff
members who restrained Harris - and who were later cleared by a grand jury -
detailed her last hours. The morning Harris died, she flouted house rules
and goaded her roommate to do the same. At breakfast, she dug into her
cereal, fingers first. When her counselor told her to stop, that it was bad
manners, she shot back a glare. In a voice loud enough for the counselor to
hear, Harris told her roommate that neither of them should obey orders.
After breakfast, on the way back to the girls' room, the counselor stopped
at a closet to get toothpaste, but Harris kept walking down the hall. When
the counselor told her to wait, Harris snapped, "I am waiting."
For this insolence, her counselor ordered her to sit on the floor of her
room and she complied without causing a problem, according to the
statements. But when a second counselor entered the room and told Harris she
would face further punishment - an hour of confinement in her room - Harris
stood up and announced she wouldn't do it. Then she sat on her bed, cool and
defiant. Her counselor warned that if she didn't get back on the floor, she
would "assist" her into the position. Two staff members closed in, one in
front, one from behind.
"Don't touch me," Harris said, throwing back one of her arms.
Instead, they forced her to the ground.
The dangers of psychiatric restraints extend beyond Texas and reach every
psychiatric facility, residential treatment center and group home where
staff members use these potentially deadly methods. Nationwide, the precise
number of restraint-related deaths each year is unknown.
A 1998 Hartford Courant survey found 142 deaths across the country in a
10-year period. Based on that report, Harvard's Center for Risk Analysis
estimated that between 50 and 150 people die annually because of psychiatric
restraints. Spurred by these reports, the General Accounting Office, the
investigative arm of Congress, identified 24 deaths across the country in
1998 linked to restraint or seclusion.
In the absence of a comprehensive federal reporting system, there is no
measuring stick to compare Texas with other states. In Texas psychiatric
hospitals, an official accounting would be impossible, Health Department
officials said.
"We don't track deaths," said Vyki Robbins, a department disclosure officer
with the compliance and licensing division in Austin. "There is not going to
be an accurate number. We do investigations on reportable complaints and
reportable incidents in our facilities. It's not reportable unless someone
complains."
Nor does the agency automatically investigate every death. If the department
receives a complaint regarding a specific death, investigators open a file.
But examiners do not classify deaths as restraint-related, even if their
findings target the restraint.
Officials at the facilities where the deaths occurred rarely disclosed
specifics.
In 1975, facing reports of abuses in psychiatric hospitals, Congress
marshaled a nationwide system of advocates to protect the rights of people
with developmental disabilities and later broadened the scope to include
people with mental illness. Advocacy Inc., the Texas arm of the federally
funded, nonprofit Protection and Advocacy system, began compiling records on
restraint-related deaths in 1998. Charged with investigating reports of
abuse and neglect, the groups have legal authority to review patient
records.
Advocacy Inc. could not determine how many restraint-related deaths it has
investigated in Texas. Like many of their counterparts in other states,
however, investigators with the group rely on news reports and hushed phone
calls - sometimes years later - from patients, staff and family members to
alert them to possible lapses. And mental-health providers often force the
group to fight for access to records in court.
Not only do providers limit the public release of such information, they
have failed to privately inform some families that restraints played a role
in the deaths.
In one case, the state initially disclosed the death of Leroy Fontenot in
precisely one line of handwritten information. Next to his case number, the
writing indicated that an unnamed, 43-year-old man died on Dec. 18, 1994,
after 15 minutes in a mechanical restraint at Vernon State Hospital. "Cause
of death: Sudden Death."
That string of facts was more than anything Wilson Fontenot had learned
about the death of his younger brother, who lived with him at his Beaumont
home before moving to Vernon.
After an attorney general's opinion on an Open Records request by the
Express-News, documents released tell a more complete story.
The day he died, Fontenot was agitated, talking loudly and bothering other
patients at Vernon State Hospital. Staff members drugged him to calm his
nerves. Instead, he got angry and attacked a staffer. At least three workers
physically restrained him, strapped him into a straitjacket, sat him in a
chair and cuffed his ankles with leather. It's not clear how long he stayed
there. Staff members documented that he appeared to fall asleep in the
straitjacket. At some point later, when it was time to release him, he was
dead, the documents showed.
A pathologist ruled that Fontenot died from a toxic level of imipramine, an
antidepressant, in his blood. The pathologist wrote that he died from the
combined effects of the high level of imipramine and the use of the
straitjacket, which restricted normal breathing and blood flow.
Wilson Fontenot's voice choked with anger when a reporter told him the
details - six years after his brother's death.
"We were told he died in his sleep," he said.
Of the cases examined by the Express-News, nine of those who died were under
the age of 18. That number squares with state and national statistics that
indicate children are more likely to be subject to restraint. Smaller and
more fragile, they are more likely to be injured or die.
It might stand to reason that state regulators would bolster the rules
governing the use of restraints on children with extra precautions. Yet
until recently, rules for the use of restraints in residential treatment
centers for children have been lax.
A year after she came to Laurel Ridge Residential Treatment Center, Roshelle
Clayborne, a 16-year-old ward of the state from Dallas, was dead.
With its sprawling campus of modern stone buildings and tidy green lawns on
San Antonio's North Side, Laurel Ridge bills itself as a model place for
children and teens prone to outbursts. Clayborne, dubbed "a hell raiser" by
the staff, fell into a routine of being restrained, then locked in
seclusion. On Aug. 18, 1997, she flew into a rage and, with a fistful of
pencils, swiped at a staff member.
Workers pinned her face to the floor in a baskethold before she started
crying that she could not breathe. Moments later, she was injected with
Thorazine, a tranquilizer, and she fell silent and stopped moving.
Soaked with urine and feces, she was rolled onto a blanket and deposited in
a locked room where she was left alone. Five minutes later, a nurse found
the girl lying in the same face-down position. But she did not attempt to
resuscitate her because there was no CPR face mask in the unit and, as she
later told investigators, it "wouldn't have worked anyway."
Citing a management breakdown and a slew of state violations, investigators
found that no one knew who was in charge the evening Clayborne died.
Four months later, the Texas Department of Protective and Regulatory
Services, which oversees 82 residential treatment centers, set out to revise
its restraint rules, setting off a contentious debate with providers
resisting more stringent regulations that would add to the cost of care.
"Our providers felt they were being punished for these few incidents. We're
not trying to punish anyone, but we realized our rules were not clear
enough," said Sasha Rasco, the agency's division administrator for
initiatives who helped develop the new rules.
Two and a half years would pass before a compromise set of rules would be in
place. And another child at Laurel Ridge would be dead.
In a series of complaints that foreshadowed Clayborne's death, the agency
investigated Laurel Ridge 10 times between March 1996 and July 1997
regarding complaints about the way staff members restrained children, TDPRS
records show. State investigators dismissed seven of the complaints, but
they ruled that, in three cases, workers broke state regulations dealing
with restraints.
In October 1996, a unit supervisor and other staff members told state
investigators that a staff member "used profanity in threatening physical
harm to the child, and threatened to kill the child," the agency's records
state.
Two months later, horseplay between a boy and a staffer on the basketball
court turned violent, with the staff member throwing the ball into the boy's
back. The worker carried the boy off the court and twice pressed the boy
face-down into a nearby pit of sand, leaving scratches and red marks.
In the subsequent investigation, the state called on Laurel Ridge to
"develop a plan that will not only ensure that staff are trained on how,
when and why restraints are to be used, but that also shows supervision is
being provided for the direct-care staff."
In March 1997, four months before Clayborne died, state investigators again
cited Laurel Ridge for violations during a restraint that left bruises on a
child's body.
Two months later, at Laurel Ridge Hospital, a branch of the facility
licensed by the Texas Department of Health, a worker slammed 15-year-old
Saidif Mejia to the floor. Mejia's mistake: he and a teen-age girl were
caught kissing.
"When I hit the floor there was this big crack. I heard my (collar) bone
break," Mejia said at his San Antonio home. "I was bleeding. I couldn't
breathe. I thought I was suffocating."
Reacting to Clayborne's death, TDPRS announced plans to revoke the
residential treatment center's license. In a contradictory message to Laurel
Ridge, the agency removed 37 children in state custody from the center, but
allowed it to stay open if it revamped its restraint rules. The state placed
Laurel Ridge on a one-year probation ending in January 1999.
A year later, Randy Steele, a 9-year-old boy from Nevada, stopped breathing
while Laurel Ridge workers pinned him face-down in a baskethold.
He died the next day. A medical examiner found that the boy suffered a heart
attack during the restraint. State investigators concluded that the staff
did nothing wrong.
If the individual snapshots are grim, the panoramic is a disturbing view of
a system flawed by inconsistent oversight, low pay for workers, poor
training and high turnover rates, advocates say.
Because of their direct, daily involvement with patients, mental-health
workers who have the least amount of expertise and experience are the staff
members most likely to restrain patients.
"If direct-care staff don't have much background in mental health and
they're not adequately trained to try and avoid these dangerous procedures,
it's a recipe for disaster. The behavior of staff can really provoke people
when it's not necessary for them to be provoked," said Andy Prough, with the
Citizens Commission on Human Rights, an Austin-based psychiatric care
watchdog group.
Rules governing the use of restraints vary according to the type of facility
and the agency that regulates it. So workers who restrain a child in a
setting regulated by TDPRS have training and follow rules that are different
from those in facilities regulated by the Texas Department of Mental Health
and Mental Retardation.
"Children migrate back and forth between these different environments," said
Sasha Rasco, with TDPRS in Austin. "We were concerned that they would have
different rights depending on where they were. We wanted to create some
consistency."
The new protective services rules, which went into effect Sept. 1, were
modeled after the stricter MHMR rules, but defenders of the disabled say the
changes fell short in some ways. Unlike MHMR, the TDPRS rules do not
routinely require that someone with medical training approve a restraint.
"These interventions have medical implications. People die. They get
physically injured. You need someone who has medical training," said Aaryce
Hayes, with Advocacy Inc. in Austin.
Among an array of more stringent MHMR restraint rules implemented in 1996,
administrators shortened the length of time a patient can be restrained and
increased the amount of contact that staff must have with doctors during the
restraint. The effect: staff used restraints less and for shorter periods of
time, said Kenny Dudley, the director of state mental health facilities at
MHMR.
"It helped put an emphasis on releasing people from restraints as soon as
possible," said Linda Logan, the agency's director of policy development.
Hayes saw the change in plainer terms.
"Doctors didn't want to be bothered. Staff had to come up with different
ways to intervene so they could head off behavior before it came to drastic
measures," Hayes said.
In 1997, Department of Mental Health and Mental Retardation administrators
began to compile statistics on how often staff in state mental health
facilities use restraints. The statistics show that the use of restraint and
seclusion varies widely among state hospitals.
"We're trying to change the thinking," Dudley said. "We're informing staff
that it's OK to walk away or stand back if someone is angry or whatever,
instead of trying to intercede. Just walk back, let it happen."
The dangers of restraints have bled into the national consciousness in
recent years.
The Health Care Financing Administration, the federal agency that oversees
Medicare spending, passed regulations in June 1999 that require hospitals to
report to the federal government any deaths in which it is "reasonable to
assume" that a patient died because of a restraint. It restricted the use of
restraints to emergency situations.
The regulations, however, cover only federally funded hospitals and leave
many private psychiatric hospitals, group homes and residential treatment
centers for children - such as Laurel Ridge - out of the loop.
Within the first eight months the rule was in place, the federal agency
reported a total of 20 deaths related to restraint and seclusion, three of
them in Texas. Advocates believe the number will rise as hospitals
increasingly comply with the rule.
Administrators predict more change is on the way.
"The most important thing that can be done is to have a common
data-collection system because it forces everyone to have a common rhetoric
and categorize (restraint-related deaths and injuries) in the same way,"
Logan said. "To have a common language about what is allowed - that's
probably the next thing on the horizon in Texas."
Despite reforms, there have been five restraint-related deaths in Texas
since November.
Among the dead was Macie Stafford, 51, who died in December at Terrell State
Hospital, where the medical director estimated that staff have decreased
their use of restraints by 90 percent in the last 10 years.
Workers held Stafford face down on the floor with pressure on his back and
injected him with Ativan, a tranquilizer. Stafford's daughter, Gale Walker,
33, placed him there when his neurosyphillis - an infection of the central
nervous system that destroys brain tissue - took a bad turn. He started
staying up all night and walking all day.
Walker said she was told only that her father suffered a heart attack. A
medical examiner ruled that he died because of mechanical asphyxia during
the restraint.
Hurt and confused, Walker wants to know the details of her father's last
moments. She wants to know why workers restrained her father. She wants to
know so badly that she dreams he's trying to provide the answers.
"Sometimes he comes in my dreams, like he's trying to tell me something,"
she said. "I ask. He just fades."
kking@express-news.net
10/21/2000
