DCF: "Death means nothing to us."

Death Brings Changes But No Guarantees

By RINKER BUCK

January 1 2006

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."

Rinker Buck is an NE staff writer.