Report reveals ‘code of silence’ at psychiatric facilities where staff abused and neglected patients | Health care

Several employees at the Choate Mental Health and Development Center tried to cover up a brutal assault on a patient, according to a new report from the Illinois Department of Human Services’ Office of Oversight.

A report by the IDHS Office of Inspector General said the “widespread attempted cover-up” surrounding the incident indicated a deep-seated “code of silence” among some workers.

The OIG report follows a series of stories by Capitol News Illinois, Lee Enterprises Midwest and ProPublica that revealed a culture of patient abuse and cover-up at a public facility in rural southern Illinois that serves people with developmental disabilities, mental illness or a combination of disorders. Reports from news organizations detailed the December 2014 beating of Blaine Reichard and the officers’ attempts to cover up the violence; The series also showed how workers accused of abuse rarely face serious consequences for their actions.

The OIG report, which came nearly eight years after Reichard’s attack, echoed many of the findings of news organizations and urged IDHS to do more to protect patient safety. News organizations requested the report when it was completed in September under the Illinois Freedom of Information Act, but the request was denied until this month.

Among the most egregious violations, the OIG investigation found that mental health technician Mark Allen held Richard in a chokehold and punched him repeatedly in the face after an argument, leaving the patient with a black eye, a busted lip and bruising to his face and upper body. The OIG additionally cited five mental health technicians for negligence after they witnessed the abuse but failed to seek medical attention for the patient or report the abuse to authorities, despite one of them later telling authorities that, apparently Reichardt “went three rounds with Mike Tyson.”

But the OIG investigation found that the problem is not limited to a few bad actors. Among the problems investigators faced when they were called to the scene: One of the mental health technicians initially lied to state police and said he was in the bathroom during the assault. The housekeeper told them she didn’t see blood in Reichard’s room, but later admitted that she did. A social worker who was in a romantic relationship with Allen tipped him off about the investigation. And the nurse and doctor made misleading statements about the extent of Reichard’s injuries, the OIG report said.

This conspiracy led the inspector general to find Choate negligent. The facility, the OIG said, should be held accountable for “failing to prevent the creation of a culture in which so many employees chose to protect their co-workers instead of protecting the abused individual, and apparently felt comfortable doing so.”

The OIG report concluded: “That so many employees participated in the cover-up of abuse [the patient] suggests that this type of behavior may be endemic in Choate.” Previous news reports revealed credible allegations of abuse in which the state attorney declined to file charges because he said the staff would not cooperate in finding out what happened.

The OIG report says it’s critical that if employees lie or withhold information during an investigation, they “feel the consequences of their actions” — and that one of the best ways to identify such collusions is through the use of video footage. The watchdog recommended installing internal security cameras at Choate to break the code of silence “from the get-go.”

In the Reichardt case, more than a year passed before anyone was arrested in connection with the beating. In 2016, Allen was charged with battery and intimidation, and three others — Kurt Ellis, Eric Bittle, and Justin Butler — with obstruction of justice. All ended up taking plea deals to lesser charges: Allen was convicted of obstruction of justice for lying to police, while the others were convicted of failing to report abuse, a misdemeanor.

But no one was prosecuted for abusing Reichard, and no one went to jail.

News reports also revealed that Allen continued to be paid for a full year after the attack, until he was criminally charged. He has since been suspended without pay and resigned in early October, a department spokesman said.

But the other three never missed a state paycheck until they were suspended pending termination last week after an OIG report found them negligent. The state paid them a combined total of more than $1 million after Reichard’s attack. Initially, they were assigned duties away from patients, such as lawn care, cooking, and laundry; they were later sent home on administrative leave.

In addition to the OIG’s findings against those who faced criminal charges, the report cited two other employees for negligence — Christopher Lingle and John “Mike” Dickerson; the report concluded that both witnessed the abuse and did not intervene or report it. Lingle continued to work until earlier this year, and is now suspended without pay pending termination. Dickerson worked at the business until he retired in 2017. He spent the last three years on the job mowing lawns in Choate.

In a statement, IDHS spokeswoman Marisa Kollias said all of the employees named in the report either resigned or were suspended pending termination after the OIG’s investigation concluded in September. She previously said IDHS cannot take disciplinary action against employees until the OIG case is complete. That investigation was suspended for eight years pending the resolution of Allen’s court case, which concluded last December.

Allen could not be reached for comment. A spokeswoman for the union representing the other employees named in the case did not respond to an email seeking information on their employment status. When contacted by reporters for an earlier story about the incident, Butler, Bittle, Ellis and Dickerson did not respond to requests for comment. Lingle, who was not named in the previous story, did not respond to a message sent through Facebook this week.

Kollias also said that in the eight years since the case began, “additional safeguards have been put in place to protect residents, patients and staff from harm”. They include bringing in Equip for Equality, an advocacy organization, to monitor conditions at the unit, setting up training on reporting abuse and neglect, beefing up security and professional staffing at Choate, and installing surveillance cameras — something the OIG has called for more than 20 times in the last five years.

(An IDHS spokesman said this week that the department has 39 cameras and plans to begin installing them this month.)

Despite the OIG’s call for stronger consequences for employees who obstruct abuse investigations, the report did not issue stronger findings against mental health technicians that would bar those employees from seeking employment in other health care settings, such as like a hospital, nursing home, or veterans home.

State law requires the OIG to report to the Illinois Department of Public Health’s Health Professional Registry the names of employees it cites for abuse or “gross negligence.” According to this law, Alena will be reported to the registry, but others will not.

Stacey Asheman, vice president of Equip for Equality, said the fact that these workers are not barred from working with vulnerable populations in the future is “very concerning.” Peter Neumer, IDHS inspector general, said his office’s general policy is not to comment on specific details of investigations or the decision-making process.

Asheman, the attorney, said the report showed the OIG felt constrained by the existing regulatory language. The report stated that the behavior of the workers who witnessed the abuse was “deeply troubling” but did not meet the legal definition of “egregious” because Allen, not the other technicians, was directly responsible for the injuries, and because the other technicians failed to report about the violence did not lead to the death of the patient or serious deterioration of his physical condition.

While he declined to comment directly on the case, Neumer hinted that legislative action may be necessary. “The OIG,” he said, “stands ready to cooperate and advocate for policy changes to further deter employees from engaging in ‘code of silence’-like behavior.”

Aschemann was more direct, saying that Illinois lawmakers should address loopholes in laws governing standards of conduct for health care professionals.

“It is clear that the laws need to be updated to introduce tougher penalties for these wrongdoings and ensure that employees who turn a blind eye to the​​​​wellbeing of people they are paid to care for are reported to the Illinois Health Care Provider Registry.” as unfit to work in medical facilities,” she said.