Report Cites Problems at State Home for Retarded

Times Staff Writer

Federal health inspectors have accused a state-run center for mentally retarded people in Pomona of serious lapses in oversight that placed residents in “immediate jeopardy” of being harmed.

During an August visit, reviewers found that 55 patient injuries at Lanterman Developmental Center had not been properly investigated by top officials there. In addition, the facility did not adequately look into three incidents “that met the definition of abuse or neglect, including a client death,” the U.S. Centers for Medicare and Medicaid Services wrote in a stinging 72-page report.

A 33-year-old client died in March after his feeding tube fell out of his abdomen and was improperly reinserted by a nurse. By the time the client was sent to a hospital the next day, infection had set in and it was too late to save him, the inspectors found.

Without an investigation by Lanterman, “a possible responsible party was not identified and safeguards were not put into place,” the federal report stated.


Because of the seriousness of the findings, Lanterman was required to immediately correct the problems to avoid losing federal funding.

Federal officials said they were satisfied with the center’s response, but last week issued a 365-page report citing additional, less serious violations. That report will not be made public until Lanterman has had a chance to respond.

“Unfortunately, for some reason, the cards are stacked against us these last few months,” said Sherry Kohler, acting executive director of Lanterman, which houses more than 600 residents. “It’s very unusual and it’s disturbing. On the other hand, it’s also an opportunity” to improve the lives of people living at the facility.

The federal findings come three months after another regulator, the California Department of Health Services, fined Lanterman $25,000 for failing to protect a 31-year-old mentally retarded man who was slain there in August 2002. Mark Orchen was kicked to death in his bedroom. No suspect has been arrested.


The report by the federal inspectors was unrelated to the killing of Orchen and did not mention his case. The inspection stemmed from an unspecified complaint, Lanterman officials said.

Lanterman is operated by the state Department of Developmental Services. Agency spokesman Paul Verke said Wednesday that he would not characterize the facility as having an inordinate number of problems.

Kohler speculated that the federal inspectors were holding Lanterman to a “much higher standard” than its peers.

But officials with the Centers for Medicare and Medicaid Services disagreed. “The requirements are the same” for all of the seven developmental centers in the state, said Steven Chickering, regional manager for the agency’s hospital and community care branch in San Francisco.


Among the inspectors’ findings:

* Lanterman did not properly supervise a resident who was placed in a time-out room for 20 minutes in May. While there, she repeatedly banged her head against the door, causing a bloody gash on her forehead.

* A woman was forced to wait nearly seven months for a mammogram after a doctor found a lump in her breast and ordered additional tests. Staff members mistakenly thought she had already had the scan.

* Lanterman staff failed to adequately monitor a resident with a history of grabbing other patients’ genitals, putting his hands down others’ pants and pulling up their shirts. Only after inspectors arrived did the facility begin tracking the resident’s actions, finding 49 incidents of sexual aggression between Aug. 7 and 11.


“Due to the facility’s lack of thorough investigation, an accurate and complete pattern of dangerous and aggressive sexual behavior was not identified,” the report said.

In other incidents cited by inspectors, a woman was placed in a jumpsuit that she could not remove, which inspectors characterized as an unsafe use of restraints. Another woman was missing for two hours before a janitor discovered her unattended in a bathroom. She was supposed to be checked on by staff members every 30 minutes.

Kohler said the facility has addressed all of the inspectors’ concerns, including requiring physicians to reinsert feeding tubes, conducting more frequent reviews of patient deaths and requiring all injuries, however minor, to be reported to Kohler.

Meanwhile, the investigation into Orchen’s killing has hit a dead end. Police suspect that Orchen was killed by a roommate, but the state Department of Developmental Services believes the homicide was committed by an employee. The Los Angeles County district attorney’s office reviewed the case again after a Times article last summer, but said “there is no real evidence as to who inflicted the blows.”


In a memo last month, Scott G. Carbaugh, assistant head deputy district attorney, concluded: “In sum, Mark Orchen was clearly a victim of criminal homicide. However, we cannot prove who inflicted the blows.... One could speculate and develop theories as to who the perpetrator is, but this would be guesswork.”

Orchen’s family has filed a lawsuit against Lanterman.