Updated Tuesday, December 18, 2012 at 08:54 PM
When lawyers for a watchdog group were combing through state files involving people with developmental disabilities, they stumbled onto a disturbing case: A paid caregiver allegedly had assaulted a resident of a state-funded group home. An examination revealed bruising around the man's genitals.
The July 2010 incident was disturbing on its own, said attorney Susan Kas, who works for the watchdog group, Disability Rights Washington (DRW). But even more troubling was what happened next.
"People witnessed this; he had an injury to the groin that was documented. And yet the abuse was unsubstantiated by state investigators," Kas said. "I was dumbfounded."
The caregiver was free to continue working with vulnerable people.
The alleged victim, 28-year-old Gregory Flood, has cerebral palsy and developmental disabilities. He is blind in one eye and deaf, and is still with the same group-home provider in Spokane.
This case and others led the group to dig deeper into the files. What they found, they say, was even more concerning. Of almost 3,000 abuse, neglect or safety-violation complaints filed in the past two years, more than 1,000 were closed by the Department of Social and Health Services (DSHS) without any investigation, according to DRW.
Even those cases that were opened often sat for weeks or months before an investigation began.
"What we found is an abuse-response system that is fatally flawed," said David Carlson, DRW's director of legal advocacy. "We need a safety net that keeps people safe. DSHS is not doing that."
For months, DSHS resisted addressing the concerns raised by DRW, the group said. DSHS does acknowledge, however, that it has too few investigators.
In fact, for the 3,000 Washington residents with disabilities who are in "supported living" homes like Flood's, there are 15 investigators. Half of them also are responsible for investigating complaints at nursing homes, assisted-living facilities and adult family homes.
Supported living is for people with developmental disabilities who in the past might have lived in a state institution. Now they live in ordinary homes, sometimes with roommates. Many also have physical disabilities or mental-health conditions.
They receive part- or full-time help from paid caregivers, as well as training in basic skills. State and federal tax dollars pay for the services. On average, this arrangement is less expensive than institutionalization.
DSHS is charged with both certifying these homes and investigating complaints of abuse or neglect.
The problem, according to DRW, is that the state often fails to get to the bottom of the abuse and neglect cases. In fact, according to a report released last month by DRW and Columbia Legal Services, the state is so lax in responding to these complaints that Washington's most vulnerable people are left open to further abuse.
The report argues that DSHS repeatedly failed to hold paid caregivers accountable for abuse or neglect. Agencies who train and hire those caregivers are rarely held accountable, either. Deaths also are not always properly investigated, the report said.
"It's not just a few times that somebody messes up," Kas concluded. "It's happening over and over and over again."
DSHS emphasized in a written statement that it "has never tolerated abuse or neglect of vulnerable children or adults and never will."
A spokeswoman for the agency said that after DRW brought the 1,000 closed cases to its attention, it took a second look at an unspecified number of them. In some cases, it determined there was an insufficient basis for investigation, the agency said. In others, the agency determined the home had fully complied with certification rules. And once again, it closed the cases without investigating the substance of the complaints.
That's exactly the problem, according to DRW. When the state receives a report of abuse or neglect, it doesn't automatically send someone out to see what happened.
Instead, it sends an investigator to look at how the care agency responded to the allegation — that is, it looks at so-called "provider practices," such as whether the agency had trained caregivers, whether it had rules in place, whether mandatory-reporting protocols were followed.
"But you still don't know whether the allegation is true," Kas said.
The agency says it has made a number of improvements in recent years, including new policies and computerized systems for handling them, says spokeswoman Kathy Spears.
But even when it does find problems, DRW says, the agency has no authority to fine most supported-living providers, even though it can fine nursing homes, assisted-living facilities and adult family homes. DRW notes there's a shortage of supported-living homes, and the last thing that it wants to do is shut one down.
Autistic twins' case
In addition to cases of alleged physical abuse, the DRW report also cites cases where the residents' lives were endangered by negligence. The story of twins Bill and Wayne Lakin, who have been diagnosed with autism, is one of them, illustrating what DRW calls state oversight.
The 63-year-olds have disabilities so profound that they never have been able to live on their own. Both have trouble communicating, and they rely on caregivers to give them proper medication.
In June 2011 the twins' brother, Jim, got a call from the Spokane home where Wayne lived. Wayne had been given a double dose of insulin — an error that could lead to seizure or death.
To Jim Lakin, the phone call was a chilling reminder of what had happened to Bill, who was suddenly hospitalized in 2007.
Doctors later determined he had been overly medicated at his supported-living home. Comatose, he was left with brain damage.
Before the medication problem, Jim Lakin said, "he could walk for miles." It was one thing that gave him pleasure.
After that, he could hobble around a little bit with a walker, but mostly he needed a wheelchair. Sometimes he dragged himself along the floor. He couldn't even get himself to the toilet anymore.
Wayne survived his double dose of insulin. But the medication errors continued, according to a log of Wayne's care. In fact, there were four documented errors the next month, and a total of 13 for a 12-month period.
The state viewed the June 2011 overdose as a "one-time, isolated event." It did not send an investigator to determine whether any individual employees were responsible, as the incidents did not meet the definition of abuse or neglect, DSHS said. The Lakins remain shaken.
Disability groups statewide say they're concerned about the findings and are setting up meetings with DSHS to discuss possible change. Sue Elliott, executive director of The Arc of Washington State, says she and other groups are working on legislation that could fix some of the systemic problems, including by hiring more investigators.
"Some of it takes money and some of it doesn't," she said. To her, the bottom line is simple: "Some of the state's most vulnerable people are being abused, and nothing is being done about it," she said. "It's very scary."
DSHS said on Friday that it will form a subcommittee to look into the issues raised by the report. It has not named the subcommittee's members.
Maureen O'Hagan: 206-464-2562 or email@example.com
KEN LAMBERT / THE SEATTLE TIMES
Jim Lakin, of Kent, learned both his autistic twin brothers, seen in a 1949 photo, have been overly medicated.
COURTESY OF JIM LAKIN
Jim Lakin is shown in 1962 flanked by his twin brothers Wayne, left, and Bill, both now in group-home care.