Orangewood Medical Care Hit in Report

County psychiatrists at the Orangewood Children’s Home placed the health of young patients in jeopardy by prescribing powerful drugs without first recording diagnoses, failing to keep accurate charts of some patients and changing drugs with great frequency, according to a highly critical report by the Juvenile Justice Commission.

The findings, contained in an executive summary obtained Thursday, are the first official confirmation of allegations made three years ago that county Health Care Agency doctors working at Orangewood failed to keep timely records and may have improperly medicated children.

“This posed a great potential risk for the children,” commission chairwoman Cynthia Stokke said in an interview. “If you are not keeping records of what drugs a child is taking, you run the risk of different drugs interacting and causing real problems.”

Orangewood is the county’s only emergency shelter and can accommodate more than 300 abused and neglected children, from toddlers to adolescents. About a third of its residents are placed in the Orange facility after being physically or emotionally abused by parents.

Stokke said the questionable practices appear to have gone on for years, though the commission noted significant improvement during the two years it was compiling the report.

The findings are based in part on several confidential reports and audits that the commission subpoenaed from Children and Youth Mental Health Services, a division of the mammoth Health Care Agency. Attorneys for the agency unsuccessfully fought the subpoena in court, arguing that the documents should remain confidential.

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Board of Supervisors Chairman William G. Steiner, who first called for an investigation into youth medication practices in 1994, said Thursday that he was disturbed by the results.

“The findings are quite alarming. Our children deserve better,” said Steiner, formerly head of Orangewood. “It seems there is a significant lack of accountability and leadership at Children and Youth Mental Services.”

Timothy P. Mullins, the county’s mental health director, acknowledged some of the problems highlighted in the report but stressed that his department had added extra staff at Orangewood and improved its record-keeping practices.

“Standard record-keeping is very important. Unless you chart it, it essentially didn’t happen,” added Mullins, who said he had not yet seen the commission report. “We’ve heard the criticism and we are doing our best to respond with more training and additional resources.”

Mullins said his department is unaware of any cases of children suffering ill effects from any drug treatment administered at Orangewood. The commission did not find evidence of patient illness.

Still, the study painted a troubling portrait of doctors prescribing drugs with little oversight or consultation with colleagues, and a department that failed to adequately investigate the allegations when they first were made. According to the report:

* “The types, amounts and the frequency of changes in the medications . . . was outside of the normal, customary practices.”

* “Deficiencies were observed in a large portion of medical charts such as a lack of documentation justifying the use of some types and doses of medications, side effects . . . and a lack of obtaining consent forms prior to administering medication.”

* After officials began looking into medication practices at Orangewood, some doctors appeared to rewrite medical charts and create new files for cases handled months before.

* There was “an apparent lack of action” in the Health Care Agency after one manager raised concerns about how doctors were medicating patients.

The report also addressed the issue of whether doctors gave adult-strength drugs to children. Based on the confidential health-care audits, the commission found that at least one “adult” drug, Risperdal, an anti-psychotic drug, was prescribed to children. But Stokke said further study is needed to determine whether use of Risperdal is actually uncommon in treating youths and whether the drug can be harmful to young patients.

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Mullins said Risperdal is considered an acceptable drug for both adults and young people and that doctors continue to prescribe it. “When you get down what is [prescriptible], it is anything that a physician believes addresses a condition,” he added.

The report also was inconclusive on the allegation that doctors performed unauthorized research at Orangewood. Of 12 officials interviewed by the commission, nine believed no research took place while three “strongly suspected” research was done. Mullins said he is unaware of any research. The nature of the alleged research has not been disclosed.

Overall, Stokke said the study found a lack of supervision and oversight at Children and Youth Mental Health Services. “The whole issue is a lack of accountability,” she said. “That describes everything that has been done. We feel there is real potential that it poses risks to children.”

Concerns over the issue first surfaced in 1994 when a former mental health supervisor at Orangewood complained to county superiors that a psychiatrist over-medicated young patients, mixed prescriptions improperly and gave children adult dosages.

Based on the charges, the board launched an audit of psychiatric medication practices at Orangewood. But the investigation fell into turmoil when one of the auditors refused to turn over her portion of the study, saying she was afraid of being sued for defamation.

The auditor finally agreed to turn over her findings, and the full report was completed in November 1995. The county refused to release it publicly, saying it contained confidential medical information.

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Steiner said he was pleased that full examination of the problem was finally receiving a public airing. He said Children and Youth Mental Health Services should prepare an “action plan” to implement the dozens of recommendations made by the commission.

He also expressed hope that the findings would not tarnish the image of Orangewood, which he stressed is run by the Social Services Agency. The home relies on the Health Care Agency for medical services.

Stokke urged health officials to respond rapidly to the recommendations, which suggest that:

* More training be provided to both doctors and staffers at Orangewood on how to deal with medications and emotionally disturbed children.

* The county make psychological assessments of all those entered into Orangewood and Juvenile Hall.

* A diagnosis be made and consent forms signed before medications are prescribed.

* The county consider creating a separate facility for mentally disturbed children.

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

In the Report

Here are the main points contained in an Orange County Juvenile Justice Commission report examining administration of mental health drugs at the Orangewood Children’s Home:

* Doctors failed to keep accurate records of what drugs were being prescribed

* Health Care Agency did not act on complaints made by a manager in 1994 about prescription practices at Orangewood

* Types, amounts and frequency of changes in medications were “outside of the normal, customary practices”

* After officials began looking into Orangewood medication practices, some doctors appeared to rewrite medical charts and create new files for cases handled months before

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* Improved training for staffers on how to deal with emotionally disturbed children on special medications

* Better communications between county psychiatrists and other staffers

* Psychological assessment for all those entering Orangewood Children’s Home and Juvenile Hall

* Required medical diagnosis and completed consent forms before prescription of medications

* Consideration of creating a separate facility for mentally disturbed children

Source: Orange County Juvenile Justice Commission