Some of Virginia’s most vulnerable allowed to die without anyone trying to save them: dLCV
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RICHMOND, Va. (WRIC) -- Dozens of people with disabilities receiving state-licensed care were allowed to die without anyone trying to save them, according to a new report from the disAbility Law Center of Virginia (dLCV).
dLCV is a state legal and advocacy organization that aims to ensure people with disabilities are safe from abuse, neglect and discrimination.
Over the course of multiple years, dLCV took a look at trends in 181 cases of unexpected death among people with Intellectual and Developmental Disabilities (IDD) under the watch of providers licensed by the Virginia Department of Behavioral Health and Developmental Services (DBHDS).
This research was reportedly prompted by concerns about a "lack of autopsies" and "inaccurate death certificates" among state-licensed providers, with the goal being "identifying preventable patterns and strengthening protections for this vulnerable population," dLCV said.
On Monday, Dec. 1, the agency released an 18-page report detailing the "alarming trends" researchers found. This includes staff failing to appropriately respond to life-or-death emergencies, as well as preventable choking deaths caused by a lack of supervision.
"Our most disturbing finding was that providers often did not respond appropriately when they found someone who was unconscious or unresponsive," dLCV said.
The average age of death of the patients in these cases was 50 years old, but the youngest was only 19 and the oldest was 83. The majority died in group homes, but some died in hospitals, supported residential homes and emergency rooms, among other locations.
In nearly half of the cases studied, these patients have little to no verbal skills -- meaning it can be very difficult or even impossible for them to communicate their suffering. They therefore rely heavily on the observations of their caretakers.
Staff did not perform CPR in a timely manner, if at all
In 46 of the 181 cases reviewed, staff did not perform CPR on a patient after finding them unresponsive. In 33 more, CPR was performed, but after a noted delay.
"When a person is found unresponsive without a pulse or breathing, the only hope they have for successful recovery is immediate life-saving care, including CPR," the dLCV said.
Reasons staff gave for not performing CPR included worry that they would catch a communicable disease, not knowing CPR and "belief that the individual was beyond saving." Others just outright refused, giving no reason behind their decision.
Notably, DBHDS requires that all licensed providers have at least one person on duty at all times who is certified in performing both CPR and first aid.
In cases where CPR was delayed, staff said they hesitated because they were calling another staff member first, were waiting on instruction from a 911 dispatcher or were "taking time to 'pull themselves together'" before acting.
Staff delayed calling 911 or did not let dispatcher help effectively
Staff delayed calling 911 in 25 of the cases dLCV examined and there were "issues" during the 911 call in 34 cases. Delays in calling were most often attributed to calling a supervisor first and the off-site supervisor then being the one to call 911, despite having no firsthand knowledge of the situation.
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These "issues" included incidents where the 911 call was complicated due to staff behavior. Examples include staff ignoring the dispatcher in favor of other conversations, not remaining calm due to their emotions, being unable or refusing to answer the dispatcher's questions or outright putting the phone down to do something else.
"Not only do these failures have serious consequences, but this has been an ongoing issue of concern known to DBHDS for several years," dLCV said.
Per dLCV, in 2018, DBHDS reported that more than half of the deaths it reviewed involved a failure to comply with established emergency protocols. This shot up to 82% in 2019 and 2020.
As of 2024, DBHDS said it is "still looking into different proven methods to improve how well providers stick to the rules."
Staff ignored food safety, intentionally put patients in harm's way
In 14 cases, patients choked to death despite having a food safety plan in place to ensure such an incident did not happen. Many of these deaths were the result of the patient not being supervised while eating, dLCV said.
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"These cases are disturbing given the fact that these individuals had a known danger of choking and the providers still failed to keep them safe," dLCV said.
In three cases, staff "deliberately" gave the person a food known to present a risk of choking or death -- meaning they "made the conscious choice to put the individual at risk and that risk led to their death," per the report.
According to the dLCV, one sponsored residential provider (SRP) had two choking deaths occur under her care and she was fired after each incident.
"However, she told the DBHDS investigator that being an SRP was her 'calling' and she intends to keep finding new licensed providers to hire her," dLCV said.
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There is currently no database where a provider can search for prior incidents like these when looking to hire someone.
Inaccurate death certificates filed, a significant lack of autopsies
Additionally, researchers found significant issues with death certificates, finding many contained incorrect details.
For example, in 1 out of every 4 cases reviewed, the cause of death was listed as a non-fatal condition, such as IDD, autism or Down syndrome. In four cases, it was listed as "mental retardation" -- which is not only not a deadly condition, but a term that is outdated and widely considered to be harmful.
"There can be no meaningful discussion of how to prevent future deaths if we do not have accurate information about why an individual died suddenly," dLCV said.
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Researchers also identified a troubling lack of autopsies performed on these patients. Only nine autopsies were performed across all 181 cases.
Notably, autopsies are not always needed, as a death from natural causes typically only necessitates a death certificate. However, given the inaccuracies found within many patients' death certificates, autopsies may have provided clarity on how they died.
On the whole, having a better understanding of why unexpected deaths happen not only brings understanding to the present moment, but it can save more lives in the future by helping staff recognize signs and symptoms of disease.
Known staffing issues further complicate handling emergencies
In half of these cases, only one staff member was on-site at the time of the deadly emergency. While the dLCV noted that this is not uncommon for group homes, especially at night, the lone staff member should then be prepared to handle emergency situations.
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Concerns raised during this investigation include:
- Caring for both the person experiencing the emergency and other patients
- Providing the necessary supervision to one patient while also being responsible for others
- Struggling to move someone in need of CPR alone
- Needing to start CPR but also needing to find the AED
- Communicating with a 911 dispatcher while also needing to help other patients
Providers repeat serious violations with little to no consequences
In several instances, DBHDS investigators identified repeated violations of the same requirement in the same year.
For example, one provider that appeared within dLCV's sampled 181 cases had four reports in which it repeated serious violations each time. In total, they did not comply with their own policies 26 times.
In another instance, a provider implemented a corrective action plan due to staff failing to give a patient CPR. Within the next month, their staff failed to give another patient CPR, per dLCV.
Finally, a provider was not cited for failing to implement a Crisis Intervention Policy because they had already been cited for the same violation before and "they were still in the same Corrective Action process."
dLCV's recommendations for how to fix these issues
The agency made two recommendations, including:
- DBHDS should require that emergency medical drills be performed regularly by licensed providers.
- DBHDS should use enhanced sanctions, such as monetary fines, in significant cases. This should include cases of neglect that could lead to or result in death, or in cases of repeat violations.
- In cases where emergency medical treatment is not provided or is delayed, when calling 911 is delayed and when food safety protocols are not followed, providers should receive either a civil penalty or have state funding withheld.
"In order to address these issues and protect those IDD individuals receiving licensed services, it is essential that DBHDS implement stronger measures immediately, including the requirement of emergency medical drills and the imposition of serious sanctions on noncompliant providers," dCLV said.
DBHDS has reportedly started to consider new regulatory requirements for emergency medical drills and staff training. However, dLCV said the process needs to be sped up.
“These reforms are moving far too slowly,” said Colleen Miller, dLCV’s Executive Director, in a press release. “Every life matters -- it is time for the Commonwealth to act.”
