In just over a three month period, ResCare employees in Kanawha County failed to administer 1,094 doses of blood pressure medication to a single person.
A client supervised by the same agency never received 873 doses of medicine, including 106 feedings and aerosol treatments for COPD. The client’s weight dropped from 73 pounds to 60 pounds.
A third client missed out on 51 doses of anti-anxiety medications and 29 doses of mood stabilizers. The client’s psychiatrist subsequently noted increased behavioral issues and urinary incontinence.
These are some of the findings of the state Office of Health Facility Licensure and Certification’s investigation into ResCare’s South Charleston agency supervising people with intellectual disabilities. ResCare staffs medical professionals and care providers who are supposed to provide care to oversee clients living independently or in group homes.
All told, the audit identifies 3,700 dosages of medication not given to eight different clients.
A review of 80 separate complaints lodged against ResCare since 2014 — which spawned state investigations that substantiated 44 of them — show the company has a demonstrable pattern of lapses in client care and inadequate staffing leading to harm in clients or clients harming others.
In six instances, these investigations came after clients’ deaths. Two came after allegations of sexual abuse against clients.
Separately from the OHFLAC complaints, a ResCare client was charged June 9 with a felony assault charge after he was allegedly left alone in a public bathroom with a young boy.
Following the South Charleston investigation, which wrapped up in April, the state issued an administrative order in early June forcing the agency to impose an admissions ban and slash its client cap from 46 to 23, starting in September. Assuming compliance, the agency can return to its current client volume after eight months.
The investigation’s findings range from clients not receiving medications; neglect not being reported; medical testing not being performed; “no narcotic accountability”; unlicensed staff checking physicians’ orders and medications; nurses not being trained; and a failure to monitor clients’ weights and blood pressures.
The findings of the most recent investigation were provided to The Charleston Gazette-Mail.
Other OHFLAC audits of ResCare agencies around the state have found care errors connected to client deaths.
In March of this year, a client supervised by ResCare staff from the Keyser agency died after consuming his nurse’s buprenorphine. The nurse had been prescribed buprenorphine for her substance abuse disorder.
Her client, along with diagnoses of autism and bipolar disorder, was diagnosed with pica — meaning he will eat objects he’s not supposed to. The client went into cardiac arrest, from which he eventually died. Hospital records indicate he tested positive for buprenorphine.
The nurse denied having brought buprenorphine into the client’s home.
Another probe found a CPR error at a Kanawha County ResCare facility proved fatal in October 2018 when a client choked on a meal.
The client’s direct care professional provided chest compressions but not rescue breathing, later telling state investigators that rescue breathing was not part of the resuscitation training she received. Another staffer took over but also failed to provide rescue breaths. OHFLAC found rescue breathing should have been performed at the time. They also identified other shortcomings with the facility’s CPR and choking training practices.
ResCare staff from the same agency entered a client’s home to find him dead in March 2018, his face a blueish-purple hue. An OHFLAC investigation found staff failed to provide bed checks every 15 minutes as the client’s sleep apnea requires.
When a Logan County ResCare client told staff he wasn’t feeling well around 3 a.m. one November night in 2018, his care provider tried to call the registered nurse on call but couldn’t get in touch with her. Though she was aware of protocol that she notify the other registered nurse on duty, she failed to do so.
The client’s mortality report states at 6 a.m., he woke up unable to breathe.
In 2017, a 13-year-old ResCare client died after he climbed through a window at a Charleston ResCare facility and drove a company vehicle into a stone retaining wall, setting the engine compartment on fire.
A client under ResCare’s Beckley agency hit her head twice before dying in 2016 — once when her wheelchair wasn’t properly secured in a company van and another time days later when she fell getting out of bed.
The investigation revealed not only the failure to secure her wheelchair, but that her bed lacked the rails she required, given damage sustained from a stroke. She fell out of bed once, before a staffer deemed her to be OK, and put her back into bed. She later fell out of bed and hit her head on her night stand.
After a tracheotomy when he was in preschool, a client cared for by ResCare’s Princeton agency required his food to be chopped and to be reminded not to eat quickly. He died when his care provider gave him a piece of bread in 2016 that wasn’t cut into pieces, as required.
Two OHFLAC probes found instances of ResCare staff sexually abusing clients.
When a ResCare client under supervision of the company’s Lewisburg agency reported she had performed oral sex on a male staffer in 2016, another ResCare employee told her she “didn’t want to hear it,” according to a state investigation.
An unsigned document in the client’s file directed staff to ignore sexual allegations she makes against staff, deeming them “sexual fantasies” that should not be given any attention.
The male staffer in question later confirmed the client’s allegation to OHFLAC.
A year prior, another ResCare staffer out of the Parkersburg location gyrated on a pool noodle in a lewd fashion in front of and to clients to describe her sex life with her husband, and told the clients to do the same to each other.
A Bridgeport man was charged with malicious assault on June 9 after he allegedly tried to touch a young boy’s genitals at a Walmart.
According to a criminal complaint from Harrison County Magistrate Court, Brent Lantz’s caretaker, Jacob Willard, waited outside the bathroom until he heard a shout from inside. The boy’s mother, who was pregnant, entered the bathroom with Willard and tried to pull Lantz from the boy. Lantz then began punching the mother in the stomach.
Jim Shaffer, a Clarksburg attorney who served as Lantz’s attorney ad litem, confirmed Lantz was a ResCare client.
A spokeswoman said DHHR is “aware of the incident and will be looking into the allegations.”
Last summer, despite specific instructions that a ResCare client not be taken into community spaces where children are likely to gather, his guardian took him to a park. There, he went on a spinning merry-go-round. He then grabbed a young boy who walked on the merry-go-round and tried to choke him, before his caretaker stopped him.
“The staff documented on the report he made [the client] stop choking the child or the outcome would not have been good,” OHFLAC’s investigation reads.
Other incidents in OHFLAC reports from 2014 to present range from clients’ infections going untreated; medications and doctor’s appointments being missed; escaping from staff supervision; clients with pica eating inedible objects like rocks, cigars or “paint water,” and others.
ResCare declined to provide an interview. Barnard Baker, a spokesman, said in a prepared statement the company is aware of the South Charleston audit and is working on a corrective plan for the “unexpected and unfortunate incidents and documentation deficiencies.” As for the June 9 incident, he said ResCare is supporting relevant authorities and “assessing any corrective actions” that are needed.
“Situations like these are not reflective of our expectations for the care and service our teams in West Virginia provide on a daily basis,” he said. “We strive for zero safety incidents and work hard to protect and monitor the complex individuals we serve.”
Allison Adler, a Department of Health and Human Resources spokeswoman, said the department cannot comment on specific details, but it takes complaints seriously and conducts thorough investigations.
“We expect and demand quality care from health care providers and our constituents deserve quality care,” she said. “When warranted, enforcement actions are assessed to further bring facilities into regulatory compliance.”
Jeremiah Underhill, legal director for Disability Rights of West Virginia, a client protection and advocacy group, said the South Charleston audit seems to be a continuation of a trend of poor supervision of people with disabilities. He regularly encounters instances of clients choking on foods they shouldn’t be eating, caretakers not knowing CPR or taking cigarette breaks when they should be supervising, or clients missing medications they desperately need.
“I’d like to say this incident is isolated, but it’s not,” he said.
However, he said ResCare doesn’t necessarily perform worse than other care providers, it just happens to dominate the lion’s share of the market, what he estimates to be more than 60 percent of people with intellectual disabilities who claim money from the state for treatment and pay for direct care services.
Of the 3,158 people with special needs in the state who go to companies to provide care, ResCare supervises 1,250 of them.
Data provided by Mark Drennan, a lobbyist and CEO of the industry’s trade group, said the Behavioral Health Providers Association serves about 5,600 people with intellectual disabilities. Baker said ResCare serves 1,250 people in the state.
According to the most recent state data, ResCare earned $54 million in revenue in 2015 at a profit margin of 16.5 percent.