State institution supervisors felt 'hopeless,' 'overwhelmed,' report says
Workers at a troubled state institution for disabled Iowans were insufficiently trained, poorly supervised, and lacked confidence to report problems, a new report says.
The report was written by consultants hired to determine “root causes” of physical and verbal abuse of residents of the Glenwood State Resource Center, which houses 230 people with severe intellectual disabilities.
“Many of the administrative and supervisory staff interviewed were overwhelmed and felt they could not adequately supervise and complete all of their required workload,” the report says. “Many of the administrative/supervisory staff were tearful, remorseful, blaming themselves for incidents at the facility over the past months. Many stated they felt hopeless to accomplish everything they are tasked to do.”
The 34-page report was written by the Joint Commission Resources consulting company, which the state hired to investigate what led to alleged physical and verbal abuse of the Glenwood institution’s residents by staff members. Thirteen staff members were fired or quit over the allegations, and six face criminal charges.
The report is labeled “confidential,” but the Iowa Department of Human Services released it Monday in response to an open-records request by The Des Moines Register.
The department, which runs the facility, disclosed in January that seven residents were physically abused and 13 residents were subjected to verbal abuse or neglect. The department referred to the abuse as “shameful,” but said it didn’t reflect the dedication of most of the facility’s 770 workers or the treatment of most of the facility’s severely disabled residents.
Department spokeswoman Amy McCoy said Monday her agency spent up to $65,000 to commission the report because it wants to understand and fix problems at the facility. “We really wanted them to go in and do a deep dive,” she said. “…We’re very serious about making changes that are necessary at the campus.”
She said the department has already implemented many of the report’s recommendations, including expanded staff training and increased supervision of front-line workers on nights and weekends.
The Iowa Department of Inspections and Appeals proposed $40,000 in fines over the allegations, which included that workers struck residents, called them "retards" and asked them humiliating sexual questions.
The facility’s superintendent retired last month, but state officials said he had decided to do so before the controversy broke open in January. A top department administrator is overseeing the facility while the department searches for a new superintendent.
Most of the abuse allegedly happened at night or on weekends in a few of the ranch-style houses where the institution’s residents live. The new report says workers had little oversight during those times. “Supervisors rotated through different homes, but evenings, nights and weekends were rarely supervised,” the report says. That changed after allegations of abuse came to light in January, it says.
The consultants found systemic problems at the facility. “The staff do not appear to take abuse allegations seriously. Rarely are staff suspended or terminated for allegations or for substantiated client abuse,” the report says. “…During interviews with staff on three shifts and in various houses, it was determined that when allegations of abuse are made against staff, they are not removed from all client contact.” Such staff members are often reassigned to work with other residents during investigations that can take months, the report says.
Sybil Finken, whose adult son, Seth, is a resident of the facility, noted the report includes praise of most of the staff. The report says employees cooperated with the assessment, and showed a “compassionate and caring nature.”
Finken contends state leaders have been moving toward closing the facility, as many other states have done. She said it’s no surprise the facility’s managers feel overwhelmed. “They’re not getting the funding and support they need from the top,” she said. “They’re just waiting for the other shoe to drop.”
Although many other states have closed such institutions, Department of Human Services leaders have said they have no plans to shutter the Glenwood institution or a similar facility in Woodward. However, they plan to continue encouraging the placement of people with intellectual disabilities in community settings instead of in the institutions.
Besides conditions such as severe autism, many of the Glenwood facility’s residents have behavioral issues, such as aggression or a compulsion to swallow inedible objects. Employees told investigators they felt inadequately trained to handle such residents, and did not have enough colleagues around them to help. “Employees report feelings of helplessness and ineffectiveness when dealing with highly aggressive, repetitively violent clients,” the report says. That leads to overuse of physical restraints and sedating medications, the consultants determined.
The investigators cited an incident in which a nurse practitioner ordered that a resident be physically restrained while a nurse administered a new anti-psychotic medication over the resident's objections. The woman was restrained for 13 minutes. “The client then engaged in self-injurious behaviors, attempting to remove the medication from her tissue. Employees were injured during the episode,” the report says. The use of physical restraints was unnecessary and violated the woman’s right to decline medication, the consultants determined.
The consultants also questioned why no managers were punished for problems at the Glenwood facility. “The supervisors and administrators have a responsibility to ensure their supervisory duties are adequate to ensure safety of the client and the staff. There is no documentation as to why only direct staff are determined in need of corrective action.”
That concern echoes criticism from the state workers’ union the day after the staff firings and resignations were announced in January. The Department of Human Services said at the time that there was no evidence of wrongdoing by any managers at the facility. McCoy confirmed Monday that no supervisors have been disciplined over the allegations.
The report says managers told the consultants they had little or no training in how to supervise other workers. Some said they learned by “trial by fire.”
The consultants suggested that allegations of abuse or neglect were not always looked into properly. “Unbiased and systematic investigations are not conducted. … Investigations were not always thorough, and all potential witnesses were not interviewed,” the report says. It also says the facility improperly had workers’ direct supervisors decide how allegations of abuse should be investigated and written up. “This gatekeeper role is not appropriate for the supervisor,” the consultants said. They also said allegations of mistreatment by staff were not always noted in residents’ files, the way reports of abuse by one resident on another resident were.
Several staff members told investigators they did not feel free to report concerns. “Employees, including registered nurses, do not believe they have the power or obligation to question authority regarding client safety or client rights.”