Disability Policy Document Archive

Abuse Continues in Indiana

Date Mailed: Tuesday, March 28th 2000 09:20 PM

The Indianapolis  Star 
     State of misery 
   Muscatatuck State Developmental Center's residents have long faced
   abuse and neglect  
   By Tim Swarens
   Star Editorial writer
   (Sun. March 5, 2000) -- 

Two state employees locked Andy in a small
   cabinet for two hours while they took an early-morning break.
   Another staff member at Muscatatuck State Developmental Center burned
   Joel with a cigarette.
                     [INLINE] Staff photo / Nikki Kahn
   TROUBLED FACILITY: One year ago, inspectors found that the Muscatatuck
    State Developmental Center violated five of eight federal health and
       safety standards. When the center missed a deadline to improve
    conditions, the federal government dropped Medicaid funding for the
        center -- a move that has so far cost Hoosiers $28 million.
   And Garth was found in his bed at the center one December morning,
   multiple clothespins pinching his genitals.
   The incidents, confirmed by state administrators responsible for the
   safety of the troubled center's 303 residents, were revealed during
   interviews with two former case managers who coordinated services for
   the three developmentally disabled men until late January.
   Two staff members were fired last fall for locking Andy in the
   cabinet. Another was dismissed for burning Joel.
   Investigators have substantiated 183 cases of abuse of residents by
   Muscatatuck staff members in the past three years. Last year alone, 75
   instances of abuse were verified.
   Since 1997, 47 state employees have been fired for abuse. Another 72
   state workers were reprimanded, but allowed to remain on the job,
   after abusing residents.
   Case manager Steve Sullivan witnessed one of those incidents of abuse,
   a fact that ultimately cost him his job.
   "I walked into the unit one day and heard a (worker) scream into a
   resident's face, "I hate your ass, and I wish I didn't have to take
   care of you,'" Sullivan said.
   Sullivan says he told another case manager about what he heard, but he
   admits that he failed to submit a written report.
                     [INLINE] Staff photo / Nikki Kahn
      IN DIRE NEED: Finding enough reliable help has been a continuing
    problem for administrators at Muscatatuck, where employees care for
      the center's severely disabled residents, many of whom need help
    bathing, dressing, eating and getting around the 80-year-old center.
   Asked to resign in January because of that failure, he has since been
   hired at New Horizon Developmental Center.
   The Muscatatuck staff member who was guilty of verbal abuse was
   suspended, but she has now returned to duty on the same unit.
   On Monday, Indiana Family and Social Services Administration officials
   implemented a tougher policy on staff abuse of residents at state
   institutions. The new policy states that employees involved in
   substantiated acts of abuse, exploitation or neglect will be
   But nobody was disciplined in the December incident involving Garth.
   Muscatatuck administrators ruled that he had abused himself with the
   clothespins, used for therapy and stored in an activity room a floor
   below Garth's bedroom.
   The state's conclusion is disputed by Sullivan and by Sue Beecher,
   case advocate with Indiana's Protection and Advocacy Services.
   "There's nothing in the records to indicate that he self-injures,"
   said Beecher, who has investigated more than 100 cases of suspected
   abuse at the center in the past year.
   Both Beecher and Sullivan saw evidence of past injuries to the man's
   "There were pinch marks all over his testicles where it had been done
   many, many times," Sullivan said.
   Garth also suffered two head injuries in the weeks surrounding the
   clothespin incident. He was once found on a bathroom floor, a gash in
   his head, blood splattered on two walls.
   "He was black and blue from the face up when I saw him," Beecher said.
   "They told me the doctor used too many sutures. He supposedly fell in
   a bathroom, but nobody witnessed it. The injuries fit a definite
   For decades, Muscatatuck has followed its own disturbing pattern.
   A scandal, often sparked by news media reports, would shove problems
   at the center into the spotlight.
   The state would then make promises -- just as it has now -- to better
   protect the hundreds of mentally and physically handicapped people at
   But after the attention faded, services to residents began to
   deteriorate again.
   A year ago this month, state administrators were once again scrambling
   to correct problems at Muscatatuck after Indiana Department of Health
   inspectors found the center in violation of five of eight federal
   health and safety standards.
   State officials were given 23 days to improve conditions at the
   center. They missed the deadline. And the federal government on April
   17 dropped Medicaid funding for Muscatatuck, a loss that has so far
   cost Indiana taxpayers almost $28 million.
   In recent months, the state has missed three of its own deadlines to
   restore funding. And in November, Debbie Simmons Wilson, director of
   Indiana's disability services, called off an inspection of the center
   after she was told that Muscatatuck still couldn't meet health and
   safety standards.
   Finally, on Feb. 23, Wilson announced a new plan to regain funding.
   Instead of attempting to have the entire center recertified at once,
   the state will allow inspectors to examine Muscatatuck in four phases.
   But the unit where Andy and Joel have been abused likely will be among
   the last inspected, at a still undetermined date.
   "I'm very concerned about Andy's safety," said Elbert Johns, his
   court-appointed health care representative.
   Safety always has been a rare commodity for Andy.
   At age 2, he was removed from his parents' Marion County home because
   of suspected abuse. And although records are sketchy, Johns believes
   that Andy lived in foster care before the state shipped him to
   Muscatatuck on March 22, 1966.
   He was 6 years old that first night he slept at the center, a little
   boy forgotten by his family and the state.
   Thirty-four years later, Andy remains at Muscatatuck, having grown
   from a wounded child into a battered adult.
   "That resident has been the victim of many instances of abuse,"
   Beecher said.
   In January, Johns requested records on all of the abuse suffered by
   Andy in the past year. Of the eight incidents investigated, four were
   confirmed as abuse.
   But Johns said he was not notified of the incident in which staff
   members forced Andy to sit in a cabinet, then locked him in so they
   could take a break. A nurse found Andy confined in the cabinet at
   about 6:30 one morning last fall.
                            [INLINE] File photo
     MUSCATATUCK THEN: According to a 1968 investigative series in The
       Indianapolis Star, more than 1,800 residents slept in crowded
     dormitories, ate food on paper plates and bathed in cold water at
     Muscatatuck State Developmental Center in Butlerville. The squalid
            conditions were linked to an outbreak of hepatitis.
                     [INLINE] Staff photo / Nikki Kahn
       MUSCATATUCK NOW: Today, about 300 people are residents at the
    facility, where the nursery that once housed nearly 200 children has
      since been converted into workshops. Housing at Muscatatuck now
   consists of single rooms or quarters built to accommodate double beds.
   After he was informed of Andy's confinement by a Star editorial
   writer, Johns requested information about the abuse from Muscatatuck
   administrators. More than two weeks later, his request still had not
   been answered.
   Beecher, who investigated the cabinet incident, said she also
   witnessed a staff member physically and verbally abuse Andy last year.
   Her report on the abuse disappeared soon after she filed it.
   "The facility couldn't find my witness statement for 24 hours. After I
   offered to write another one, it was found," Beecher said.
   Andy has been injured so often that staff members have begun to blame
   him for the center's failure to regain Medicaid funding.
   Former case manager Randy Johnson says state employees have even given
   Andy a nickname: the $36 million man.
   The nickname reflects the state's total cost of losing federal
   funding. It also reflects that Andy has become a scapegoat for the
   failure of Indiana's leaders to ensure a safe institution.
   Johnson was hired in April by Liberty Healthcare, a Pennsylvania
   management firm awarded a $7 million contract to turn around the
   failing center. Although he has worked in developmental services since
   1977, Johnson was shocked by what he witnessed at the institution.
   "I've never encountered anything like Muscatatuck. I never knew it got
   that bad," said Johnson, now employed by Catholic Social Services in
   Johnson said he resigned in late January because of tensions between
   Liberty employees and state workers.
   "There are a lot of scared people down there. It's a very hostile
   environment. We were way out there in the middle of nowhere and
   everybody was going crazy," he said.
   One of Johnson's responsibilities was to write a behavioral plan for
   Andy, a script that details daily activities for each resident.
   Direct-care staff members learn their roles from the plan. Plans also
   are designed to extinguish residents' more destructive behaviors by
   keeping them busy.
   But Johnson said he was told to constantly rewrite plans for Andy,
   partially because staff members balked at the amount of work involved
   in certain activities, including regular trips to an indoor swimming
   pool on the grounds.
   Johnson said that one of Andy's few joys is wading in the pool. But
   staff members objected because they had to enter the pool with Andy to
   keep him safe.
   Elbert Johns, who has represented Andy since 1993, met with
   Muscatatuck administrators in November to request that an appropriate
   plan be implemented for Andy.
   "I was assured that significant resources would be provided for Andy.
   I went back a month later and not a damn thing had been done," Johns
   On Feb. 10, Andy's new plan finally was adopted. Johns said Andy's
   demeanor improved almost immediately.
   "He's making good progress now because he's not in the same building
   all the time. If you're in the same room for 168 hours a week, you're
   going to react in negative ways," Johns said.
   Some things never change
   The roots of Andy's current struggles can be found in Muscatatuck's
   tarnished past.
   In 1967, Dr. Joseph Denniston was hired as superintendent of the
   institution, spread over 2,400 acres in Jennings County. He was
   appalled by what he encountered.
   Denniston, a pediatrician, opened the center's wards to Star reporter
   Michael Tarpey and photographer William Oates, who documented the
   center's horrid conditions in a three-part series published in
   February 1968.
   The first-day, front page headline read: "Forgotten patients live in
   world of filth."
   The 1,807 residents slept in crowded dormitories and bathed in cold
   water. They ate cold food on paper plates because only one of the
   center's dishwashers worked.
   Denniston said overcrowding and poor sanitation had led to an outbreak
   of hepatitis. Reporter Tarpey described a gagging stench from a filthy
   grease trap in the central kitchen.
   It was common in those days for mentally handicapped infants to be
   sent directly to Muscatatuck from hospital maternity wards. Nearly 200
   children languished in the center's nursery with little attention from
   the few adults on duty.
   "We have a problem of child development. We are not educating the
   patients, nor are we able to teach them self-help," Denniston said.
   One of those neglected children was Andy, an 8-year-old when The Star
   series was published.
   At the time, Denniston was pleading with state leaders for more money
   to hire additional workers. In a women's dormitory, one attendant was
   expected to care for 36 residents.
   By 1999, Muscatatuck's population had declined dramatically. Fewer
   than 400 residents lived on the grounds, the youngest in his early
   20s. The nursery had been converted into workshops where residents
   crush cans and shred paper.
   Cindy Speer, who has worked at Muscatatuck for 23 years, says
   conditions at the center improved greatly in the late '70s after the
   state won Medicaid funding.
   But administrators still struggled last year to hire enough employees
   to care for the disabled residents, many of whom need help with
   bathing, dressing and feeding.
   The large number of unfilled positions was noted in a scathing Justice
   Department report, released June 15, about dangerous conditions at
   Muscatatuck and the state's other developmental center in Fort Wayne.
   "Because of direct care staffing shortages (including approximately
   190 funded slots at Muscatatuck and 50 vacancies at Fort Wayne) and
   supervision deficiencies, the facilities do not detect or record many
   instances of harm. The facilities categorize numerous injuries as
   unwitnessed, with causation left unresolved. In some instances, staff
   do not tally incidents but, instead, bury them in resident progress
   notes and behavior data. They thus escape necessary risk management
   review," the report said.
   Financial finagling
   The large number of vacant positions was not caused by a lack of
   funding. Between 1997 and 1999, Muscatatuck's administrators failed to
   spend almost $20 million of funds budgeted to hire and pay staff
   Some of the money was sent back to Indianapolis because of
   state-mandated budget reversions, a practice put in place during the
   Evan Bayh administration. Money also was transferred to other state
   As a result, money appropriated by legislators to pay for adequate
   care of Muscatatuck residents was used by state officials for other
   purposes. x
   Family and Social Services Administration officials cite an inability
   to recruit workers for the center's large budget reversions.
   For decades, Muscatatuck has been the largest employer in sparsely
   populated Jennings County in southeastern Indiana. Many staff members
   live in North Vernon. With a population of 5,800, its the county's
   biggest town.
   Working at Muscatatuck has become a tradition for some North Vernon
   families. Sons and daughters now tend the grounds and staff the wards
   where their parents worked years ago.
   But as the region's economy grew stronger, the often stressful jobs at
   Muscatatuck became less attractive. Staff members must change adults
   diapers, feed and bathe disabled residents and corral others who
   wander away from group activities. Andy, for instance, needs constant
   supervision to keep him from falling or bumping into furniture and
   While the starting salary for direct-care staff was increased 15
   percent last year, to $8.51 an hour, workers can make more money at
   less demanding jobs in Seymour, a short drive west on U.S. 50.
   To fill 70 direct-care positions last year, the state was forced to
   rely on Liberty Healthcare, originally hired to improve management at
   the center. Liberty employees are paid better than state workers, even
   when they perform the same duties.
   Former case managers Johnson and Sullivan say that disparity has
   heightened tensions among Liberty and state employees.
   "I'm not sure Debbie Wilson realizes how serious the problems are,"
   Beecher, the case advocate, said.
   Wilson, director of the state agency responsible for Muscatatuck,
   moved to the Butlerville campus in October to assume direct control of
   the center. She returned to Indianapolis after Muscatatuck failed to
   meet its Dec. 31 deadline for recertification.
   Questions about closure
   The repeated failures stoke the fears of families with disabled sons
   and daughters at the center.
   "The parents are worried that the problems will be used as an excuse
   to close the center," said Frances Egner, president of the Muscatatuck
   Parents Association.
   Egner's 29-year-old daughter has lived at the center for 10 years.
   In the past three years, Indiana has shut down two of its centers for
   the developmentally disabled. And the national trend has been away
   from large institutions toward small, home-like settings for the
   mentally handicapped.
   But parents like Egner question whether their children will be safe in
   smaller settings, where paid caregivers receive even less oversight
   than in institutions.
   The threat of a shutdown also worries state employees like Don
   Williams, whose letter to the editor to a local newspaper remains on
   display in the administration building at Muscatatuck.
   "Most of the clientele were happy here at (Muscatatuck) until some
   educated idiot convinced them they weren't," Williams wrote.
   For now, Gov. Frank O'Bannon has promised that Muscatatuck will remain
   But the center's population will continue to decrease. Another 74
   residents moved from the center into community settings last year. And
   Muscatatuck, with a sprawling campus and more than two dozen
   buildings, becomes less feasible with each resident who departs.
   Elbert Johns dreams of the day when Andy is one of those who can
   permanently leave Muscatatuck.
   He hopes soon to become Andy's legal guardian and to start the process
   by which the 40-year-old man could for the first time have a home to
   call his own.
   "We hear that we need places like Muscatatuck for the people who are
   the hardest to serve. They're hard to serve because they're in places
   like Muscatatuck," Johns said.
   Burned by cigarettes. Locked in cabinets. Screamed and cursed at by
   the people paid to care for them. If some Muscatatuck residents have
   become hard to handle, their anger and fear appear to be
   The state, meanwhile, still struggles to bring Muscatatuck up to
   minimal federal standards.
   "A comprehensive reform takes time," Debbie Wilson said last June
   after the Justice Department report documented hundreds of injuries at
   the state's two institutions for the mentally handicapped.
   After 34 years, Andy is still waiting for the state to reform
   Muscatatuck. Joel, Garth and 300 others are waiting as well.
   Swarens is a Star editorial writer. His e-mail address is
   tswarens@starnews.com   [INLINE]   Institutions in trouble 
   Indiana's institutions have a long history of problems with patient
   care. Here's a look at a few of the incidents that made headlines in
   the past decade.
   o March 20, 1992: Central State Hospital patient Linda Heine drowns.
   Hospital employees later admit they were playing cards or napping the
   night she died. Seven workers are fired.
   An Indianapolis Star investigation finds that 27 patients had died
   during the preceding five years. Only nine of the deaths were from
   natural causes.
   o June 23, 1992: Gov. Evan Bayh announces that Central State Hospital
   in Indianapolis will close by June 30, 1994.
   o July 23, 1997: Gov. Frank O'Bannon announces that the New Castle
   State Developmental Center will close.
   In April, a Indiana State Department of Health inspection had found
   that the center failed to protect the rights of 138 of its residents.
   In the preceding year, inspectors said, 167 residents had suffered
   injuries of unknown origin.
   In May, a hidden camera report by Indianapolis TV station WISH,
   Channel 8, had shown a resident being hit in the head with a clipboard
   by a psychiatric assistant. Another resident was tied to a chair, and
   others were cursed by staff members.
   o July 24, 1997: The Department of Health releases inspection results
   from the Fort Wayne State Developmental Center. Inspectors found 193
   cases of unexplained injuries at the center during the preceding year.
   The department also found 32 violations of federal rules.
   o Feb. 23, 1999: The Department of Health announces that the
   Muscatatuck State Developmental Center failed to meet five of eight
   standards for participation in the Medicaid program.
   Investigators found eight incidents in which residents were abused,
   including four that resulted in serious injuries.
   State officials are given 23 days to correct conditions or lose
   Medicaid funding, which pays two-thirds of the center's budget.
   o March 6, 1999: The state announces that Muscatatuck Superintendent
   Michael Coppol has resigned.
   o March 19, 1999: State health inspectors inform Family and Social
   Services Administration officials that Muscatatuck will lose Medicaid
   funding on April 18.
   o March 22, 1999: Gov. Frank O'Bannon visits Muscatatuck, pledging
   that the center will remain open. "Muscatatuck has always been a very
   strong, outstanding center," he tells staff members gathered in a
   A week later, Liberty Healthcare, a Pennsylvania management firm,
   takes over daily operations at Muscatatuck.
   o June 15, 1999: The U.S. Department of Justice releases results of an
   investigation into the Fort Wayne and Muscatatuck developmental
   Federal investigators found that 88 percent of the Fort Wayne
   residents had suffered more than one injury in the first eight months
   of 1998. At Muscatatuck, 76 percent of residents suffered multiple
   injuries in the first 10 months of 1998.
   o June 16, 1999: Terry J. Best, dean of boys at the Indiana Soldiers
   and Sailors Children's Home, is suspended without pay for allegedly
   supervising a May 28 party in which students at the home were
   suspected of drinking liquor and smoking cigarettes.
   Best later was charged with five felony counts for drug possession,
   one felony count of neglecting a dependent, one misdemeanor count of
   possessing marijuana and one misdemeanor count of contributing to the
   delinquency of a minor.
   The charges resulted from an Indiana State Police search of Best's
   office at the children's home. Police found drugs and drug
   paraphernalia, prescription drugs, lingerie, pictures of students, and
   pornographic magazines and videotapes.
   o Aug. 5, 1999: Muscatatuck Superintendent Richard O'Brien resigns
   after investigators confirmed that he had a sexual relationship with a
   male subordinate.
   O'Brien later was cleared in a separate inquiry launched after it was
   learned that he had twice taken a male resident off the grounds
   without following signout procedures.
   o Aug. 9, 1999: The Department of Health releases a report saying that
   not enough has been done to ensure residents' safety at the Fort Wayne
   State Developmental Center. Ensuring resident safety is one of eight
   requirements centers must meet to participate in Medicaid funding.
   Inspectors said staff members failed to control a resident who bit,
   scratched and pinched another resident for months. The center reported
   353 injuries of residents in the first seven months of 1999.
   In September, inspectors returned to the center and found that
   problems had been sufficiently corrected to meet Medicaid standards.
   o Sept. 10, 1999: Dwayne Uminiski, assistant superintendent of
   Logansport State Hospital, is suspended and barred from the grounds
   after he is accused of sexual misconduct with a mentally ill patient.
   o Nov. 4, 1999: Debra Simmons Wilson, director of disability services
   in Indiana, cancels a Department of Health inspection after she is
   told that Muscatatuck will be given a failing report.
   o Dec. 24, 1999: The state announces that it will not meet its
   self-imposed Dec. 31 deadline for bringing Muscatatuck into compliance
   with federal health and safety standards.
   The loss of Medicaid funding cost Indiana taxpayers more than $21
   million in the final eight months of the year. An additional $7
   million was paid to Liberty Healthcare to improve conditions at the

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