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How we analyzed abuse and injury cases at developmental centers

California relies on a variety of standards to report abuse and injuries at the state’s five institutions for the developmentally disabled, where about 1,800 patients with cerebral palsy, severe autism and other disorders live.

As such, it is difficult to determine the precise number of times that staff members have abused patients or that patients have injured themselves or another patient.

The most comprehensive information on incidents at developmental centers comes from the Health Facilities Consumer Information System. Operated by the state Department of Public Health, the database lists inspection records for all allegations of regulatory violations at care facilities.

These violations include a wide range of offenses, including poor medical care, sloppy recordkeeping, invasions of privacy, physical assaults and all deaths. The database shows when the allegation was reported to the Department of Public Health in Sacramento and whether regulators substantiated the violation during a review or inspection.

California Watch took a conservative approach to crunching the numbers from the Department of Public Health.

In reporting about the Office of Protective Services, we included in our analysis only substantiated cases of patient abuse and those classified as “injuries of unknown origin.” State policy requires that police investigate these unexplained injuries as potential abuse cases.

Yet, not every abuse case is listed in a straightforward manner.

The Department of Public Health classifies some cases of abuse, including sexual assaults, as “patient rights” violations. That label is applied to an array of incidents – privacy infringements among them – and California Watch excluded them from its analysis. The state simply doesn’t provide enough information to make an informed analysis of the available data.

As a result, the patient abuse numbers we reported are an undercount.

The Department of Public Health contends that allegations of abuse in “substantiated” case files do not necessarily mean a patient has been abused. That’s because multiple allegations – including physical abuse, unexplained injuries, accidents, neglect and poor medical care – can be logged under a single case file from a single incident.

Under federal rules, if any allegation is proven to be true, the entire case file is listed as substantiated. For example, the Department of Public Health inspector may have found a patient was neglected, but not physically abused, in a file that contains allegations of both. The department contends it’s impossible to determine an exact number of substantiated abuse cases, because they are intermingled with non-abuse allegations in the same file.

But a California Watch analysis of data from the Health Facilities Consumer Information System reveals this scenario is highly unlikely. Out of 394 cases of substantiated patient abuse since 2004, only 16 have other allegations included in their case file.

The department lists “neglect” and “accidents” separately from abuse and other injuries. Neglect includes patients left unattended in dangerous situations or other lapses in regular, non-medical care. Accidents may include falls or minor injuries that were witnessed.

There is no publicly available national data on patient abuse and unexplained injuries at developmental centers. Regulations and criminal statutes vary from state to state, making comparisons difficult. For that reason, we have not attempted to compare the volume of incidents in California with other states.

Instead, we used the inspection data to document the number of abuse and injury cases the Office of Protective Services is required to investigate each year at the five operating developmental centers. The Agnews and Sierra Vista institutions – located in San Jose and Yuba City, respectively – closed in 2009 and were excluded from the analysis.

The overall number of substantiated abuse and unexplained injury cases increased from 2008 to 2010. Reports of substantiated abuse have increased 43 percent during those three years. Unexplained injuries have increased 8 percent in the same period.

Patient populations at the developmental centers are shrinking quickly. We calculated rates of abuse and unexplained injuries per 100 patients to better measure the frequency of incidents from one year to the next. The developmental centers take a patient census four times a year. We used the highest population count from each facility, each year, to generate the rates.

Finally, in our examination of a fatal injury in 2007 at the Fairview Developmental Center, California Watch provided law enforcement experts with the case file on the death of Van Ingraham, 50. The homicide investigators were asked to provide an independent analysis of the case.

Detectives Mark Czworniak with the Chicago Police Department and Al Cruise with the Seattle Police Department examined hundreds of pages of documents. Their written reviews agreed on six errors in the institution’s basic police work on the case.

This story was edited by Robert Salladay and Mark Katches. It was copy edited by Nikki Frick.


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