Accusations of rape, abuse and improper restraint at the Beatrice State Developmental Center were contained in a federal report released Tuesday.
According to the 14-page document from the Centers for Medicare and Medicaid Services, a BSDC patient reported being raped by another client, staff members threatened to physically harm patients, and one client suffered a black eye after being improperly restrained.
On Friday, federal officials reported that the center failed to meet minimum standards, and found three areas in which clients were in “immediate jeopardy,” prompting the resignation of director Vince Benjamin.
Rene Ferdinand, administrator for HHS's developmental disabilities system, took over Friday as the center's acting administrator, and other people from the central state office were brought in to oversee changes.
“The contents of this report were rather distressing,” Ferdinand said in an interview with the Daily Sun Wednesday morning. “Some of the details we talked about Friday, but it was still rather depressing to see them in print.”
Ferdinand said state officials were taking the report seriously, and were working on a plan to correct the deficiencies.
“We're not disputing what they said,” Ferdinand said, “but what we're doing is seeing, is the system broken, was it an isolated incident, what changes do we have to make?”
The unannounced survey started on Sept. 18 and lasted until Sept. 29. The three instances of “immediate jeopardy” found were:
n On Sept. 14, an 18-year-old female client reported that an 18-year-old male client raped her in the reading room at the on-grounds school, according to the report.
Investigators found that the client accused of rape was supposed to be under 24-hour supervision for “inappropriate sexual behavior,” but was not being watched.
In fact, staff did not know the client was supposed to have special supervision and did not provide special supervision to any of its clients, according to the report.
Some staff involved in that incident have been suspended pending an investigation by the Nebraska State Patrol, Ferdinand said.
He said that, because of privacy laws, he could not say whether the man accused of rape was still a patient at the center.
n The investigation found that the center did not follow up on many claims of abuse, and did not take measures to correct them in a timely manner.
Further, staff who were being investigated for allegations of abuse were not suspended, as is required under facility policy.
In one case, a staff member told a hospitalized client, “I'm going to beat you within an inch of your life if you don't settle down.”
An internal investigation said that while the staff member's behavior was inappropriate, “it is not believed that the statements made to the client ... were made with the intent to verbally abuse the client.”
The staff member continued to work with clients at the center after the internal investigation, according to the federal report.
Numerous injuries of unknown origin, some with accompanying allegations of abuse, were not reported to the center's administrator, or were reported and no corrective action was taken.
n The investigation also found that the center did not have a policy for assessing the use of restraints after clients suffered injuries, a measure that is supposed to be used to prevent such injuries in the future.
In one case, a client needed outpatient care for a black eye and abrasions to the spine, arm, hip and buttock. Other clients had bruises or reddening on their arms. Internal reports on the incidents did not indicate any consideration of how to keep such injuries from occurring again, the federal report said.
The state has 23 days to respond to the findings of “immediate jeopardy” with a plan of correction, Ferdinand said.
Other deficiencies may be detailed in a comprehensive report from the federal investigators that is due Oct. 16. The state will then have 90 days to respond to that report.
In addition, in an Oct. 2 letter to Ferdinand, the Centers for Medicare and Medicaid Services said the Beatrice center's Medicaid provider agreement would be terminated Oct. 22.
The center could reapply to participate in the programs after it demonstrates compliance for 30 days, the letter said.
Ferdinand said BSDC staff has been proactive in responding to the situation.
He said staff immediately began investigations to make sure all clients were safe.
“The safety and health of our clients are our top priority,” he said.
He and staff members are also analyzing the federal report released Tuesday to ensure its accuracy, determine if the incidents were isolated or widespread and see if further procedural changes are needed.
Further actions, he said, include working with staff to develop a plan of correction which he hopes to have in draft form by Friday. Following that, he expected to have a conference call with CMMS officials in Kansas City, while the CMMS likely would send a federal survey team to inspect operations and buildings on all shifts.
Gov. Dave Heineman said Friday that he had ordered Health and Human Services officials to take immediate steps to ensure the safety and well-being of those served at the Beatrice facility.
“Obviously the governor was displeased with the findings, but he's made it clear that improvements will be made, and changes are already under way,” Aaron Sanderford, Heineman's spokesman, said Tuesday.
The Associated Press contributed to this report.