The state Department of Children and
Families took immediate remedial
steps to improve conditions at the
Trumbull facility for medically
fragile children where 2-year-old
Leeana Candelario died in April -
the victim of apparent incompetent
care and neglect.
But DCF can't guarantee that
tragedies such as Leeana's death
won't happen again. Although the
state officials said they have
confidence in the group home, they
conceded that staffers there made a
number of bad decisions.
That was part of the message
delivered by DCF Commissioner
Darlene Dunbar and two aides during
an hour-long question-and-answer
session with NE staff members last
week. The meeting followed a Dec. 18
story in the magazine by Kevin
Rennie examining what went wrong in
the care of Leeana as detailed in a
40-page confidential report by DCF's
Special Investigations Unit.
The child, who had a tracheostomy,
died of respiratory failure - a
result of the staff's failure to
properly clear her breathing tube
and their inability to handle the
ensuing emergency.
DCF's Response To The Death
Accompanied by Lou Ando, chief of
DCF's Behavioral Health Unit, and
DCF spokesman Gary Kleeblatt, Dunbar
answered questions from Rennie,
reporter Colin Poitras and NE editor
Jenifer Frank. The commissioner
described how the agency instituted
a "corrective action plan" at
Trumbull House, an affiliate of St.
Vincent's Medical Center in
Bridgeport, after Leeana's death
there. Similar actions were taken at
a sister facility in Stratford.
"What happens when you have such a
tragic outcome and occurrence of
death of a child is we immediately
stop admissions, and we use that
period of time with any provider to
assess," the commissioner said. "Do
we think, first of all, that the
children who are still in that
facility are safe? And that's what
we immediately determined. ...Then
we look at the over-arching issues
of what else here potentially needs
to be corrected, or at least
assessed for what else should be
corrected."
Ando described the corrective plan.
Ando: "When we first went in to look
at their program, there were issues
around documentation of training. We
wanted to be sure that staff were
trained. At a program like St.
Vincent's, the needs of each child
were unique, and so there needed to
be a lot of individual,
child-specific training. So our
first issue was to be sure that the
people who were there knew how to
deal with the kids who were there.
To not further complicate that, we
didn't allow any further admissions
until we were sure that it was safe
for those kids, that the staff there
knew how to deal with them.
"And so the corrective action plan
that was developed - actually it was
developed by them and we approved it
- consisted of a training plan, a
training program, being sure it was
documented appropriately and staff
were appropriately trained, and
secondly the addition of licensed
personnel to oversee those kinds of
functions."
Rennie: "Do you mean more
supervisors?
Ando: "I mean a pediatrician, I mean
an APRN [advance practice registered
nurse], a couple of RNs [registered
nurses], house supervisors, that
kind of stuff."
Dunbar: "In the Trumbull location,
the staffing almost doubled and the
[compensation] rate was reassessed
to support that and also the
increased administrative presence."
Trust In Staff Qualifications
Rennie and Frank questioned Dunbar
about the adequacy of the licensing
process for such facilities.
Rennie: "St. Vincent's had been open
several years. Why weren't any of
these things done before Leanna
died?"
Dunbar: "From a contracting seat,
the facility was fully licensed. And
with the licensure met, we then rely
on - in this case particularly - a
medical facility, a medical-based
model to really honor the
requirements of what would be
required for best care."
Rennie: "But something terrible went
wrong, and the report indicates that
someone could have easily detected
that if they'd been paying attention
to St. Vincent's. There was frequent
turnover, inexperienced personnel,
people who had really never worked
with children, a lot of workers who
had been in geriatrics. Why did it
take until Leeana Candelario died to
somehow have this sort of review
conducted?"
Dunbar: "We do trust that -
especially in this case, which was a
medical model - that a registered
nurse would know the requirements of
what that licensure required and
what that job is - that a licensed
practical nurse would be able to
meet those same standards. So we do,
as a state, rely on the facility
providing what that care is supposed
to be. In this case, you are exactly
right. With this experience and this
example, this was a failure. And
this was a failure to assure that
that best practice was there."
Rennie: "Were there any alarms
raised during the licensure period,
since that was going on at the same
time?"
Dunbar: "I don't believe so. No,
there weren't."
Frank: "And St. Vincent's was
licensed by whom?"
Ando: "By DCF. Our quarterly license
review was done in January. We were
due for another review in early
May."
Afraid To Question Care
The Special Investigations Unit
report also described how one nurse
who complained about the lack of
qualifications of her supervisor was
told that she could quit her job if
she couldn't get along with her
boss. This and other examples
suggested to Rennie that a culture
of fear surrounded the group home.
Its employees worried about
retribution if they complained to
higher management about poor medical
practices.
Rennie: "What have you done to
address the issue of fear of
retribution among employees? ...
Throughout [the report], the
employees were saying, `I knew we
were in over our heads, I was afraid
to say anything.' Your [work] shifts
would be split [if they complained].
"They refer to a loving atmosphere
at Trumbull House. There was nothing
loving going there on among the
employees ..."
Dunbar: "Well, I think when you
raise the level of expertise of the
folks that you are working with, and
you try to really start taking more
of a leadership role as well, and
you have a greater administrative
presence so you're all starting to
know more about what's occurring on
a day-to-day basis - I think all of
that tremendously helps. I think the
increased training and the increased
focus on their development, and on
listening to what they say are
concerns, and what they say needs to
be corrected - I think that's making
a difference there."
Rennie: "Do you tell employees that
there are ways for them to alert the
department to problems without their
names being disclosed?"
Dunbar: "I would assume they know,
but we have certainly made sure that
employees knew about being able to
call the hot line, through being
anonymous. You can still request
anonymity. So I think staff are
aware that they don't have to say
their name. I think just generally
there is some - I think fear is too
strong, but some wondering about
that as far as not leaving their
name - because usually when people
say the information, you know it's
from someone in the facility."
Rennie: "Someone called right after
[Leeana] had died."
Dunbar: "And what that says to me is
that people are taking that a little
more seriously and are able to speak
up ... I know that's what we're
interested in having there. And I
know that's what the leadership at
St. Vincent's is committed to
sharing. But absolutely, we
absolutely need that and demand
that, because the only way to assure
that children are safe anywhere is
really that everybody recognizes
that they're a piece of that and
that we have ways, like the request
for anonymity, to be able to bring
issues to the forefront."
Ando: "If I can add two things:
First of all, one of the changes we
initiated which we hoped to address
... fear of retribution is always
difficult to address, difficult to
get your arms around.
Rennie: "It's not difficult if you
say to the people running the place,
`If you dare do anything to these
workers who are telling us the
truth, we'll cut off your
contract.'"
Ando: "What we asked for was that a
house manager be put in charge of
each of these facilities, which
hadn't been the case prior. ... Our
expectation was that the primary
role of these house managers would
be to find things that needed
improvement ... We told them we were
not looking at a punishment-oriented
perspective but were looking at a
quality-improvement perspective. We
wanted them to identify deficits
that we could tackle. We don't
expect there's going to be
retribution for those reports."
No Guarantees Against Tragedy
St. Vincent's was supposed to have
been a temporary placement for
Leeana. Her medical needs were not
severe enough to require long-term
hospitalization, but the state could
not immediately organize
professional home care for her
either, although this might have
eventually been the goal. So she was
placed at a facility that was
"appropriate," Dunbar said, but not
intended as a long-term solution.
"Certainly there was not a range of
options to be able to meet this
individual little girl's needs,"
Dunbar said. "We have around 250
children that need this kind of
level of support in their homes, in
foster homes and other places. This
is a struggle, because the other
piece that this story shows so much
about - and DCF has no better way to
solve this than the rest of the
state or the rest of the country -
is basically a question of nursing,
the availability of nurses, the
availability of the appropriately
trained nursing for every level of
care you need at the times you need
them.
"If you're looking to have such a
highly complex amount of nursing in
a family home," the commissioner
said, "can you really get that
nursing for all the hours you need
it, and can you get it where you
are? And that certainly showed up in
this case."
But the problems go well beyond the
national shortage of nurses. The
sheer number of children with
special medical needs makes it
difficult for any state agency to
guarantee that another tragedy like
Leeana's won't happen.
"In any facility, in any place
actually, there is always the chance
for a tragedy to occur, "Dunbar
said. "We deal with that. Our work
is human-based. So you start from
that premise. The goal is that it's
zero [errors], absolutely, but we do
know ... a state system that
operates with people as its
operational core is not able to
guarantee 100 percent safety in any
placement. Accidents happen.
"So I would start with the premise
that individual children are being
cared for appropriately at St.
Vincent's. There was a tragedy,
absolutely - there is a lot of
feeling associated with that on
everyone's part - but there are
individual children there at St.
Vincent's today who we believe are
being appropriately cared for. ...
For us, we have to assure that with
this death, we have some ownership
about how we make sure the system
changes, gets better and keeps
strengthening that work."