Reports of neglect threaten Rosewood

 

11/09/06
By Linda Strowbridge


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Editor's Note: This is the first of a two-part story about the Rosewood Center in Owings Mills. The second part will appear next week.

Disabled-rights organizations are demanding the state close Rosewood Center in the wake of a monitor's report detailing numerous episodes of violence and neglect at the Owings Mills facility.

Investigators for the state's Office of Health Care Quality uncovered so many incidents of residents hurting themselves and each other in September that they concluded residents faced "immediate jeopardy." Investigators issued a citation to Rosewood threatening to terminate the facility's Medicaid funds.

Rosewood addressed the state's "immediate jeopardy" concerns before a late-October deadline and retained its Medicaid support.

Acting director Joanne Knapp said Rosewood staff members have developed new care plans for eight residents who were identified as facing immediate jeopardy.

The facility enacted a seven-step process to protect victims of abuse, Knapp said, and adopted a 24-hour deadline for getting additional psychiatric care for any resident who has a violent episode.

Staff members are receiving new training, she said, and the facility is making greater use of contract psychologists.

"Essentially, the fire is out, but we still have concerns," said Wendy Kronmiller, director of the Offfice of Health Care Quality. She plans to send inspectors back to Rosewood for a second, extensive review in the near future.

On Nov. 6, Kronmiller's office rejected Rosewood's proposal to correct systemic problems, saying Rosewood lacked "credible evidence" of enhanced staff training, safety procedures and psychology services. Rosewood must produce an acceptable plan by Nov. 16 or face financial penalties.

Disabled-rights activists say the state's report highlights long-standing patterns of violence, neglect and civil rights violations at Rosewood that likely can't be changed.

They say Rosewood residents would receive superior and cheaper care, greater freedom and improved quality of life if the state closed the facility and moved residents to community-based facilities.

"This is not a facility you are going to turn around," said Lauren Young, director of litigation for the Maryland Disability Law Center , which has tracked problems at Rosewood since the 1980s.

"They've had several different directors and brought in different consultants over the years. But there are chronic problems in that environment that concern us greatly," Young said.

Broken ribs, death threats

Established in the 1800s as an "asylum and training school for the feeble-minded," Rosewood currently houses 203 adults and children with serious developmental disabilities and psychiatric disorders.

The resident population includes individuals who have been deemed mentally incompetent to stand trial.

In the Sept. 26 citation letter to Rosewood, the Office of Health Care Quality stated that investigators "determined that the facility failed to ensure that individuals are free from abuse, neglect and mistreatment and that the potential for harm existed."

Investigators focused on incidents involving eight residents. They included:

*A man, with a history of physical assaults, self-inflicted injuries and suicidal gestures, broke through two locked doors at Rosewood, then ran full-speed, head-first into a trash receptacle, colliding with sufficient force to move it off its foundation. He hit his head twice more on the receptacle, then stuck his arm inside it and repeatedly closed the door on the limb. Staff did not attempt to restrain him.

*A man who was admitted to Rosewood as a 6-year-old in 1958 and readmitted several times, suffered from mental retardation, pedophilia and substance abuse and often made racially offensive comments. Within a three-month period this summer, he was the victim of three physical assaults resulting in several broken ribs and other injuries, one act of sexual harassment and one death threat by other residents. Rosewood staff, investigators concluded, not only failed to safeguard the man but allowed him and his main attacker to live in the same cottage.

*A 45-year-old woman with profound mental retardation and a history of self-injury attacked herself or others 10 times within a two-month period. In one instance, she repeatedly hit her head on a radiator and required sutures to close the wounds. The staff's efforts to calm her regularly failed, and Rosewood's psychiatric staff failed to produce a requested plan to better manage the woman's behavior.

In about half the incidents cited in the report, investigators concluded that Rosewood officials failed to complete thorough investigations and failed to protect the injured resident from further abuse.

Unfixable

Members of the Disability Law Center say that incidents of abuse and other forms of mistreatment or neglect at Rosewood have gone unreported for years.

Rosewood workers produced few reports of injury or abuse, even though the reports are required by law, until they received training in the procedure a few years ago, Young said.

"But the numbers are pretty staggering still on incidents that they do not report," said Rachel London, an attorney with the law center who has represented Rosewood residents for the past two years.

Meanwhile, investigators for the Office of Health Care Quality gave Rosewood virtually spotless reports in recent years, Young said.

"That raised lots of red flags for us," Young said, suggesting that the reports were incomplete.

Kronmiller, who became director of the Office of Health Care Quality in April, said she couldn't comment on how investigations were completed in the past.

She said she has added investigators to a department that was severely understaffed and made some management changes that affected the investigations.

Conditions at Rosewood, Young said, "didn't just suddenly get to be an immediate jeopardy situation."

"It's not that things changed drastically there," she said. "It's that the people doing the reviews changed, and they were looking more carefully."

The Office of Health Care Quality reports confirm that these conditions exist and that residents are in jeopardy, London said.

"The state was failing to protect them," she added.

Brian Cox, executive director of Maryland 's Developmental Disabilities Council, said the state monitor's report is the latest in a long line of reasons to close Rosewood.

In an October letter, Cox and the leaders of four other disabled rights organizations called on Gov. Robert Ehrlich to develop a plan by Dec. 31 to close Rosewood and implement that plan within two years.

"There has been rights violations and noncompliance with federal standards for decades at Rosewood," the letter stated. "We do not believe the broken facility can be fixed."

Next week: Rosewood's habits of dealing with behavior problems, psychiatric care, education and physical restraint/isolation have subjected residents to rights violations, advocates for the disabled say. Maryland , they insist, could provide higher-quality and lower-cost care through community-based services.