Home for Retarded Failed to Prevent Death, State Alleges

State health inspectors are accusing a state-run home for retarded adults of violations that include the overdose death of a 33-year-old man, the mysterious poisoning of a 40-year-old woman and the staff’s use of a stun gun on a young man.

The state Department of Health Services has issued at least 15 citations, carrying penalties totaling $142,800, since January against the Sonoma Developmental Center in the Northern California town of Glen Ellen.

The documents cite an incident in which a female staff member sexually fondled a male patient, and two instances in which staffers hit residents. In three instances, staff members were seen sleeping on the job. In other instances, staff neglected patients by failing to protect them from falls and from the sexual overtures of other residents.

The violations are among the most serious filed in three years against any of the five state centers where 3,850 developmentally disabled people receive round-the-clock care.

Because of the state citations, as well as extensive inspection reports, the federal Health Care Financing Agency refused to recertify the center and moved to cut the flow of $3 million in monthly Medicaid dollars to the picturesque, 130-year-old campus.

The center and the state Department of Developmental Services appealed the federal action; there has been no resolution yet.

The violations at the home in Sonoma County come less than three years after federal inspectors documented deaths and unsanitary conditions in California’s homes for retarded, autistic and otherwise developmentally disabled adults. California officials promised reform at the time.

Timothy Meeker, director of the Sonoma Developmental Center, called some of his staff’s behavior “criminal” and “indefensible.”

But he also noted that since federal inspectors started accompanying state surveyors two years ago, the size of inspection reports have increased tenfold.

“I believe that through increased training and scrutiny and urging,” he said, “the federal government is putting increased pressure on state surveyors to perform at a different level than they have in the past.”

The increased scrutiny leads to “everything, from what I consider pretty Mickey-Mouse items all the way up to what I consider pretty important issues. . . . They all violate some standards,” he said.

Janice Caldwell, associate regional administrator for the Health Care Financing Administration in San Francisco, acknowledged that the presence of federal inspectors could lead to more exacting inspections by the state.

“It’s perfectly human nature that when someone is watching what you’re doing, you’re just a bit more careful,” she said.

Most serious of the 15 violations at the Sonoma center, according to the state citations, is the failure to prevent harm to a severely retarded man with an impulse-control disorder.

The man, unidentified in citation reports, died June 14, 1999. The Sonoma County coroner’s office, based on toxicology reports and an autopsy, listed the cause of death as an overdose of an anti-depressant drug.

The coroner’s office could not classify the death as accidental, natural, homicide or suicide, said Sonoma County Sheriff’s Sgt. Roy Gourley, and turned over its reports to investigators with the state Department of Developmental Services.

That overdose incident, Gourley said, prompted the Sonoma County coroner to establish a policy of gathering fluid samples for toxicology tests from every resident who dies at the Sonoma Developmental Center.

Meeker said state investigators are still looking into the death, and that there appears to be no irregularities in how staff medicated the man.

However, the death prompted the state Department of Health Services to issue “class AA” citation--the most serious level of citation--against the Sonoma center. A similar citation was issued against the center in 1999 after a resident choked to death on restaurant food as he was being driven to a local park for an outing.

This year, another state center for developmentally disabled people, the Agnews Developmental Center in San Jose, received a “class AA” citation for an incident in which a patient walked away from the home and was struck and killed by a car.

Still under investigation at the Sonoma Developmental Center is the July 1999 overdose of a 40-year-old woman with a seizure disorder and history of ingesting inedible objects. The woman was seen July 20 spinning in circles and stumbling against walls before she collapsed unconscious, according to the state citation. Doctors found toxic levels of opiates in her blood.

It’s not clear where or how the woman ingested narcotics, Meeker said. “Entire shifts of people were given lie detector tests,” he said. “There seems to be no perpetrator at this point that we can identify.”

Meeker said he has fired three employees for sleeping on duty in the seven years he has run the 1,600-acre wine country campus. Employees suspected of abuse or neglect are always immediately placed on administrative leave, he said. One such employee was a psychiatric technician accused of hurting a 24-year-old profoundly retarded man with a stun gun in August 1999. Meeker said the Sonoma County district attorney’s office has charged the technician with abuse of a dependent adult.

District attorney officials Friday could not confirm that a staff member at the Sonoma center had been arrested or charged in the incident.

The center’s appeal of the federal move to cut off Medicaid reimbursements, which make up about 30% of the center’s $130-million annual budget, sets the stage for an evidentiary hearing before an administrative law judge--the first of its kind, state officials say. It promises to pit the inspectors at the Department of Health Services against employees in the sister agency that runs California’s homes for developmentally disabled adults. Both agencies fall under the state Health and Human Services Agency.

That close bureaucratic relationship between operators and inspectors meant for many years that fines imposed for resident neglect or abuse were never collected, said Human Services spokeswoman Lea Brooks. But Gov. Gray Davis recently directed that fines be collected, even if the money is moving from one state agency to another.

Cliff Allenby, director of the Department of Developmental Services, said oversight of California’s five developmental centers may need to be restructured so that the federal government alone handles inspections and enforcement.

“There is a clear disagreement between our departments,” he said.

The San Jose center last year lost its certification from the federal government, and state tax money is being spent to make up the lost Medicaid money. Other centers in Los Angeles and Orange counties meet federal certification, said Caldwell.

“It’s a matter of who’s in charge and how hard they try,” she said.