Disability Rights Arkansas, which has been investigating conditions and practices at the Booneville Human Development Center for a couple of years and which in 2015 recommend the state close the HDC over its dilapidated building and its practices of physical and chemical restraint, today issued a report that said a patient there choked to death because of the facility’s “outdated and primitive responses to behaviors.”  

It is the third report issued by the disability rights organization about Booneville.

The disability group went to Booneville in April 2015 to investigate reports of a 24-year-old woman who had been restrained more than 40 times for a total of 36 hours and 49 minutes. But when members of the group arrived, they learned that the woman, identified as Jane, was dead: She’d died in February after choking on food. The group then began to investigate Jane’s death, according to Tom Masseau, executive director of DRA.

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From the report

DRA’s investigation revealed that not only was Jane the victim of excessive restraint, she also was the victim of dangerous “treatment” that led to the development and implementation of a behavior treatment program that ignored serious medical concerns, including Jane’s known risk of choking and history of seizure episodes that included falling, jerking, and vomiting.

There were both choking and seizure precautions ordered for Jane in the years preceding her death. Those precautions were meant to ensure her safety around food to avoid choking incidents and to provide appropriate action in the event of choking or seizure. Yet these precautions were ignored when a tragic and dangerous decision was made to implement a Behavior Treatment Program that emphasized ignoring any behavior that resembled a seizure because it was believed that Jane was deliberately engaging in the seizure-like episodes to
garner attention.

The Behavior Treatment Program for Jane was fatally flawed because it did not acknowledge the conflicts between the choking and seizure precautions required for Jane’s safety and the directive that staff ignore her seizure-like episodes. The Behavior Treatment Program was implemented despite concern expressed by direct care staff to the facility’s Director of Nursing that the Program caused direct care staff to act outside of their qualifications.

Ultimately, Jane choked to death because of a disregard for choking and seizure precautions. Although Jane’s death was not due to a restraint, she did die as a result of the outdated and primitive responses to behaviors used at the Booneville HDC that dangerously combined with a lack of coordination in medical and behavioral care that left her, and continues to leave other residents, at risk of injury and death. 

In today’s announcement of the report, Masseau said, “From our investigations of Booneville HDC, a clear picture has been painted — the facility is a poorly run, relic of the past, which does not provide adequate, safe treatment for residents.” 

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The report says the state gave “only a cursory look” at the circumstances of Jane’s death. The DRA recommends that the state Department of Human Services and the Division of Developmental Disabilities Services hire an independent expert to study the treatment of the residents at the Booneville HDC, evaluate each resident for their specific treatment needs and recommend treatment and housing needs and “implement a more rigorous, independent review of treatment decisions, practices and incidents, including deaths.”

The Booneville center is one of five intermediate facilities for people with development disabilities. Most have a dual diagnosis of mental illness in addition to developmental disabilities.  

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The DRA’s first report, “A New Approach to Care in Arkansas: Why the Time Has Come to Close the Booneville Human Development Center,” issued in January 2015, cited the dilapidated condition of the facilities on campus and concerns about the use of restraints. Today’s report comes on the heels of a Jan. 14, 2016, report, “Bound to the Past: The Excessive Use of Restraint at Booneville Human Development Center,” which detailed what DRA says is excessive use of drugs and physical means to restrain residents. After the Jan. 14 release, Masseau said that because of the facility’s reliance on restraints to handle behavior, “The potential for injury or loss of life is greatly increased.”

In response to the DRA’s January 2015 report, Amy Webb, a spokesman for DHS said the agency was “acutely aware of the condition of the buildings” and said improvements were needed, “but they would take a great deal of money that we do not currently have. So, instead, were are doing everything we can to ensure the residents are safe and comfortable.” Webb also said that nurses check on residents who’ve been given drugs to restrain them and that staff reviews all incident reports. She attributed the higher use of restraints at Booneville than other HDCS because of the diagnoses of its resident population. 

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Responding to the Jan. 14, 2016, report, Webb said the agency was taking the DRA’s concerns “seriously,” and had reviewed its restraint policies at all of the state’s human development centers. She repeated that much of the resident population at Booneville has dual diagnoses and said “these residents will likely always need a closely-supervised, high-level of care due to their clinically-complicated needs. Despite the potential for dangerous behaviors, BHDC only uses restraint interventions in emergency situations, often only after other de-escalation techniques did not calm the resident. Emergency interventions are not used out of convenience or for punishment.”

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