When federal investigators descended on a Colorado home for people with intellectual and developmental disabilities, asking about alleged abuse, staff members had an easy answer.
Amid allegations of abuse in March 2015, the Colorado Department of Human Services deployed investigators to conduct wellness “body audits” of residents of the Pueblo Regional Center. Body audits are strip searches of a patient to search for evidence of physical abuse.
The state-led body audits were reported to the Colorado Department of Public Health and Environment by a third party raising concerns about consent for the body audits. The Department of Health Care Policy and Financing then notified the federal Centers for Medicare and Medicaid Services, which came in to investigate the audits and the alleged abuses further.
Now an August 2016 CMS report, first obtained by the Denver Post, details abuses and infractions at the PRC, the latest iteration of allegations of abuse and mismanagement. And it highlights the vulnerabilities of developmentally and intellectually disabled adults, who sometimes fall through the cracks of oversight systems.
The alleged abuses at the PRC include “several male residents having words scratched on their backs and chests,” according to a copy of the CMS report obtained by The Daily Beast. “It appears that words were scratched into the individuals using a fingernail.”
The words included the terms “die,” “kill,” “no,” “I’m back,” and “No J.”
When The Daily Beast attempted to get the Pueblo County Sheriff’s Office records for the alleged scratching incident, a woman in the records department said it would be almost impossible to find the incident without more specific information.
The official estimated there are between 10 and 12 incident reports filed with the sheriff’s office per month relating to the PRC facility.
The words were scratched into patients with “significant intellectual disabilities,” some of whom cannot communicate verbally, according to the federal report. It notes that the Sheriff’s Office substantiated that incident of abuse.
But staff members told investigators they had no part in the mysterious scratches, although they shared them on social media, the report says. Instead they blamed the abuse on “paranormal activity,” though other staffers say they haven’t seen any evidence to support this claim.
“I haven’t heard nothing about that,” Gabriel Jiron, who is still a health care technician at the PRC, told The Daily Beast. He would not comment on the alleged abuse.
One former staff member told The Daily Beast that there might be a more earthly answer: a staff prank.
A licensed psychiatric technician, whom we’ll call Cathy because she asked to remain anonymous, worked at the PRC for four years and knows many people who still work at the center.
“They were trying to play a prank on one of the male nurses,” she said. “On one of those residents they had written ‘Go away,’” referring to a male nurse.
The report only cites an inscription of “No J.” But Cathy says the nurse did not find this prank funny—and quickly quit. (The Daily Beast was not able to independently verify this account, and a spokeswoman for the Colorado Department of Human Services said she could not comment on personnel issues.)
But quitting was a course of action common for the more conscientious employees, according to Cathy.
“I saw physical abuse. A lot of physical abuse. And when we reported it, nothing was ever done,” she said. “They still kept the ones that were abusive even though we turned them in plenty of times.”
Scott Moore, who worked at a nearby mental health facility and had several children work at the PRC, echoed Cathy’s sentiments.
One of his sons resigned, signing a nondisclosure agreement. “But I didn’t,” Moore said.
“There’s a lot of alleged abuse going on there,” he said. But is it true?
“In some cases yes, in most cases no,” Moore said. “In other cases, there’s alleged abuse to run employees out.”
Other abuses cited in the report include two residents dying of bowel obstructions because the PRC staff treated them only with “melted butter and prune juice,” rather than medications. Another patient died because staff members thought he had a “do not resuscitate” order when he did not, according to the report.
Non-lethal abuses included staff burning a patient by using “a blow dryer on her legs to raise her body temperature” and locking “a resident out of the group home in the cold for two hours as a means to punish him.” Another allegation said a resident performed a “sexual act on a PRC staff member in exchange for a soda.”
Some of the incidents were exposed during a state audit in 2015 but covered in more detail in the CMS report.
Many of the individuals in the PRC’s care are nonverbal and rely on staff care and attention. But the investigation found a high employee turnover rate and frequent reports of people being asked to work back-to-back double shifts. The annual turnover rate was nearly 40 percent, compared to the CMS’s recommended 20 percent or lower.
“They’re exhausted because they’re working double shifts. And back-to-back double shifts,” Stephanie Garcia, the executive director of the Arc of Pueblo, an advocacy organization that has legal guardianship of some of the residents, told The Daily Beast. “How did somebody else not see this? And then not report it until this finally came to a head in April 2015?”
Garcia first became aware of the allegations that spring, after the state Department of Human Services performed “body audits”—strip searches—on patients.
“We were told they did that because there were serious allegations of abuse at the Regional Center,” she said. “And the reaction of the state was to go in and abuse people again by doing strip searches.”
Systems that should’ve been protecting residents “failed. All the way around,” she said.
Eleven people were placed on administrative leave after the body audits. But KKTV reports that eight people were fired during the federal investigation and eight others disciplined.
The CMS ruled that “current staffing for PRC is not adequate to serve additional clients” and suggested that the center put a moratorium on new clients. It also demanded reimbursement for federal funds.
“At the moment, the state is contesting our findings,” Mark Fierberg, a spokesman for the CMS, told The Daily Beast.
“CMS, which oversees federal dollars spent at PRC, has recommended that we do not admit new residents at PRC until staff turnover is reduced,” the Colorado Department of Human Services said in a statement. “CMS also may disallow Medicaid expenditures at PRC from November of 2014 to November of 2015, a move that could require the state to refund to the federal government the Medicaid dollars spent there during that timeframe. The state is considering appealing both of these recommendations.”
Meanwhile, the department said it has submitted a plan to address the other concerns in the report.
“We are confident that all of the changes that PRC has made since the uncovering of abuse and neglect will result in a better environment for both our staff and our regional center residents,” the statement said. “We have made a lot of progress in regional center operations and we look forward to working with our state and federal partners to continue our improvement efforts.”