Aspies For Freedom

Group home faulted in autistic boy's death
He choked on his own vomit while being held; CEO disputes the report

BY MICHAEL MARTZ
TIMES-DISPATCH
Feb 2, 2006


On Dec. 23, 2004, a 13-year-old boy choked to death on his own vomit while being held face down on the floor of a Winchester group home by as many as six members of the staff paid to care for him.

The boy, who was autistic and mentally ***, had arrived the day before at the group home operated at 920 Frederick Ave. by Grafton School Inc., one of Virginia's biggest providers of care for youths with behavioral problems and disabilities. He was placed in the Grafton facility, about five hours from his home in Southwest Virginia, because of aggressive behavior that had caused him to be committed to two state institutions earlier that year.

A state investigation of the death has concluded that the group home's staff was uninformed and ill-prepared to handle the boy, who was 6 feet tall, weighed 241 pounds and had limited ability to express himself. The investigation, completed last month, also found that the staff used an inappropriate form of restraint on the boy and did not relent until he began to turn blue.

"There is evidence to support that staff continued to hold [the boy] in a lying-down restraint when he began vomiting," the report states in respect to one of 12 alleged violations of Virginia interdepartmental regulations for group homes. "Vomiting is a sign of distress. Staff ignored vomiting as a sign of distress."

The home's staff also failed to respond quickly enough to the boy's dis- tress with mouth-to-mouth resuscitation, partly because the necessary safety equipment couldn't be found, the report states.

Grafton, a nonprofit organization that has operated in Virginia since 1958, was to deliver a required plan to state officials today to correct the problems identified by the investigation.

However, Grafton Chief Executive Officer James G. Gaynor II took strong exception to the state report. "We're certainly very much in disagreement with many of the findings," he said Tuesday.

Group homes are a hot topic in this year's General Assembly session because of concerns about the care they provide, as well as their relationships with their surrounding communities. Most of the care is publicly funded by state and local governments, or the federal Medicaid program.

The homes are licensed by different agencies responsible for children and adolescents, using a common set of interdepartmental regulations. In Grafton's case, the Virginia Department of Education is the state agency that licensed the home and led the investigation.

However, the education department was assisted by the Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services, and its Office of Human Rights.

The Winchester Department of Social Services also participated in the investigation but issued a separate report based on child protective service regulations. The report found that the group home was not guilty of abuse and neglect under those rules in the boy's death.

In addition to violations of interdepartmental regulations for group homes, the state investigation cites Grafton for eight alleged violations of state mental-health standards and eight alleged violations of human-rights standards for people in therapeutic programs. The most serious was the alleged lack of information about the boy's behavior and medical condition when he was admitted to the home.

"The information collected at the point of admission is significantly inadequate, especially medical information," the mental health department states.

Virginia already has issued Grafton a six-month provisional license for the group home at 920 Frederick Ave., according to the education department. The provisional license is a temporary measure to allow the owner to make changes in the way it operates the home and cares for its residents to bring it into compliance with state regulations.

Grafton, based in Winchester, operates 23 group homes across Virginia, including 12 in the Richmond area, and a large residential facility in Berryville. Each home is licensed separately, so the investigation's findings apply only to the home in which the boy died.

The nonprofit organization has been a linchpin for care of people with behavioral problems related to developmental disabilities, especially autism. The Virginia Autism Resource Center, with offices in Midlothian and Winchester, is a division of Grafton.

Mount Rogers Community Services Board, the Marion-based agency that referred the boy to Grafton, would not comment on the case or the report.

However, Executive Director Lisa Moore said Grafton is an important option for communities that cannot find the special care these children need closer to their homes. "Grafton is a resource that we use once we've explored everything else," she said.

Moore added that her agency also tries to find help for children outside of state institutions. "I don't think being in an institution for a long time is a good alternative either," she said.

The boy, whose name was blacked out of a report provided to The Times-Dispatch by the Department of Education under the Freedom of Information Act, had been admitted to the Southwestern Virginia Training Center in Hillsville twice in 2004 to give his family respite from behavior that had become increasingly aggressive at home and school, the report said.

In November 2004, he was admitted to the Southwestern Mental Health Institute in Marion, where he remained until he was admitted to Grafton on Dec. 22, 2004, the day before he died. The state investigation found that the group home had not collected information about his stay at the training center and partial information from the mental hospital.

"This is particularly troublesome," the report states, "when it is understood, that prior to admission to Grafton, the student spent considerable time at these two facilities."


Contact staff writer Michael Martz at mmartz@timesdispatch.com or (804) 649-6964.

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Grafton criticizes Va.'s findings in AS boy's death

BY MICHAEL MARTZ
RICHMOND TIMES-DISPATCH
Feb 4, 2006


Grafton School Inc. says Virginia regulators aren't telling the truth about the death of a 13-year-old autistic boy at a group home the organization operates in Winchester.

James G. Gaynor II, chief executive officer of the nonprofit corporation, told state officials this week that their investigation of the boy's death on Dec. 23, 2004, at Grafton's 920 Frederick Ave. group home was unfair and was contradicted by other accounts of the fatal incident.

The investigation, a multiagency review led by the state Department of Education, determined that the boy choked on his own vomit while being held face down on the floor of the group home by as many as six caregivers employed by Grafton. The report said he was not released until the staff noticed that he was turning blue.

The state cited Grafton for allegedly violating 12 provisions of the regulations that govern group homes in Virginia, as well as eight violations of mental-health regulations and eight provisions of human-rights regulations.

A separate review by the department last year found that Grafton had reported nine serious incidents at the home from Sept. 1, 2003, through Aug. 31, 2005.

In a three-page letter sent to state officials Thursday afternoon, Gaynor challenged the probe into the 13-year-old boy's death.

"Overall, the process by the interdepartmental agency review team appears orchestrated to achieve a predetermined outcome -- the establishment of Grafton's responsibility for the child's death when all evidence indicates otherwise," he wrote.

In addition to the letter, Grafton provided regulators with a detailed response to each regulatory citation and recommendation in the report. It disagreed with the issuance of many of the citations.

The Department of Education regulates 23 group homes operated by Grafton, including 12 in the Richmond area, and a residential facility in Berryville. "The intent of our investigation was not to lay responsibility on any party for the death of the student," spokesman Charles B. Pyle said. "It was to determine whether and how interdepartmental regulations were violated."

The 20-page report states that the group home's staff was uninformed and ill-prepared to handle the boy, who arrived a day before his death after spending more than a month in a state mental hospital in Southwest Virginia. The boy was autistic, *** and had limited ability to express himself. He also was 6 feet tall and weighed 241 pounds.

The state investigation found that the group home's staff had little information about the boy, his behavior and his medical condition before he was admitted.

In October, the Department of Education issued the group home a six-month provisional license after a separate review of the facility's license. It found that Grafton had reported nine serious incidents at the home from Sept. 1, 2003, through Aug. 31, 2005, and that state investigation of eight of them resulted in findings of one or more violations of group-home regulations.

In response to the state investigation of the boy's death, Grafton said the report was contradicted by a separate investigation conducted by the Winchester Department of Social Services, which accompanied the state team's two-day visit to the home in early 2005. The social-services report concluded that the home was not guilty of child abuse and neglect, as defined under state laws and regulations for child protective services.

"It is troubling that partners in an investigation can produce such divergent representations of the facts and yet your report does not even acknowledge such difference exists," Gaynor wrote to Sandra E. Ruffin, director of federal program monitoring at the Department of Education.

Education officials said they were not investigating whether abuse or neglect had occurred -- they said they were enforcing the state's regulations for operating group homes. They were joined in the investigation by the Department of Mental Health, Mental Retardation and Substance Abuse Services and its Office of Human Rights.

Leslie Anderson, director of licensing for the state mental-health department, said, "It is easier under our statute to find abuse and neglect than it is under child protective services. . . . Theirs is geared toward intentionality."

But Gaynor cited specific findings of fact by the social-services investigation that differed from the account in the state report. He provided The Times-Dispatch with a copy of the report by the local agency.

The report states that the group home's staff restrained the boy because he was "out of control" and had assaulted another resident. The staff removed other residents and attempted to restrain him by both arms.

The report states that the home's staff used the term "take down," which is a type of restraint prohibited by standard procedures. But it adds that "there is no evidence available to show that the child was forcefully taken to the floor by staff. Interviews suggest that the child [laid] down on the floor himself, guided by the two staff."

Once on the floor, the boy began to vomit. "Once again, [the] facts of the case show no evidence that the child was forcefully held on the floor while he vomited," the social-services report states.

It says the boy raised himself to his elbows while vomiting and, according to differing accounts, that the staff either backed off or stayed in contact with him without using "a confining restraint."

When the boy began to turn blue, the report says, the staff began immediate CPR, summoned a nurse and called 911. "The autopsy by the state medical examiner also cited heart problems of the child as a contributing cause of death," the social-services report states.

Gaynor, in a letter yesterday to parents of children enrolled in Grafton programs, said the medical examiner "found no evidence of trauma to the child and did not believe the restraint procedures caused or contributed to the student's death."

The state report gives the medical examiner's cause of death as asphyxiation on vomit "during an excited state while restrained."

Anderson, the state mental health licensing director, confirmed that the boy had a heart problem, "which is another reason why he shouldn't have been restrained," she said.

Winchester police investigated the death, but no criminal charges were filed. The Times-Dispatch has asked to see the police file on the case under the Virginia Freedom of Information Act.


Contact staff writer Michael Martz at mmartz@timesdispatch.com or (804) 649-6964.

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