This article was prepared for ProPublica’s Local Reporting Network in partnership with Lee Enterprises and Capitol News Illinois. Sign up for Dispatches to receive stories like these as soon as they are published.
Several employees at the Choate Mental Health and Developmental Center tried to cover up a brutal attack on a patient, according to a new report from the Illinois Department of Human Services Surveillance Office.
The IDHS Office of Inspector General’s report says that the “widespread attempt at cover-up” surrounding the incident indicates an ingrained “code of silence” among some workers.
The OIG report comes after a series of stories from Capitol News Illinois, Lee Enterprises Midwest and ProPublica that reveal a culture of patient abuse and cover-ups at the state-run facility in rural southern Illinois that kills people with developmental disabilities, mental illnesses or a combination of disorders. News outlet reports detailed Blaine Reichard’s caning in December 2014 and staffers’ attempts to cover up the abuse; The series also showed how workers who face allegations of abuse rarely face serious consequences for their actions.
The OIG report, which comes nearly eight years after the Reichard attack, echoed many of the news organizations’ findings and urged IDHS to do more to protect patient safety. The news organizations had requested the report when it was finalized under the Illinois Freedom of Information Act in September, but the request was denied until this month.
Among the most egregious violations, the OIG investigation found that psychiatrist Mark Allen held Reichard in a chokehold and repeatedly slapped him in the face after the two argued, leaving the patient with two black eyes, a busted lip and bruised face Upper body. The OIG also charged five psychiatric technicians with neglect after they witnessed the abuse but did not seek medical attention for the patient or report the abuse to authorities, although one of them later told authorities it appeared that it was Reichard “went away”. three rounds with Mike Tyson.”
But the OIG investigation showed that the problem wasn’t limited to a few bad actors. Among the challenges investigators faced when they were called to the scene: One of the psychiatrists initially lied to state police, saying he was in the bathroom at the time of the abuse. A housekeeper told them she had not seen any blood in Reichard’s room, but later admitted she had. A social worker who was associated with Allen leaked information about the investigation to him. And a nurse and doctor made misleading statements about the extent of Reichard’s injuries, the OIG report said.
This collusion led the Inspector General to believe Choate himself to be negligent. The facility, according to the OIG, should be held responsible for “failing to prevent the establishment of a culture where so many employees chose to protect their colleagues rather than protect an abused individual and seemed comfortable doing so.” “.
The OIG report concluded: “That so many employees were involved in covering up the abuse [the patient] suggests this type of behavior may be endemic in Choate.” Earlier news outlet reports revealed credible abuse allegations in which the prosecutor declined to pursue charges because he said staff were not cooperating to find out what has happened.
The OIG report said it is “crucial” that when employees lie or withhold information in an investigation “the consequences for their actions are met” – and that one of the best ways to identify such conspiracies is through the use of video footage . The watchdog recommended installing indoor security cameras in Choate to break the code of silence “from the start”.
In the Reichard case, more than a year passed before anyone was arrested in connection with the beating. In 2016, Allen was charged with assault and intimidation, and three others – Curt Ellis, Eric Bittle and Justin Butler – were charged with obstruction of justice. All eventually accepted pleas for reduced fees: Allen was convicted of the felony of obstruction of justice for lying to police, and the others were convicted of failing to report the abuse, a misdemeanor.
But no one was criminally held responsible for Reichard’s abuse, and no one was serving a prison sentence.
News organizations’ coverage also showed 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 had never missed a state paycheck until they were suspended pending termination last week after the OIG report found them negligent. The state has paid them more than a million dollars in total since Reichard’s attack. At first they were tasked with tasks away from patients, such as lawn care, cooking, and laundry; later they were sent home on administrative leave.
In addition to the OIG’s findings against those prosecuted, the report cited two other employees for neglect – 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 facility until his retirement in 2017. In his last three years he mowed the lawns in Choate.
In a statement, IDHS spokeswoman Marisa Kollias said all employees named in the report were either terminated or suspended pending dismissal after the OIG investigation concluded in September. She previously said IDHS could not take disciplinary action against the staff until the OIG case was closed. That investigation was suspended for eight years pending the settlement of Allen’s court case, which closed last December.
Allen could not be reached for comment. A spokesman for the union representing the other workers named in the case did not respond to an email asking for information on their employment status. When reporters asked them for an earlier article 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 via Facebook this week.
Kollias also said that in the eight years since the case began, “extra safety precautions have been taken to protect residents, patients and staff from harm.” These changes include bringing on Equip for Equality, a legal advocacy organization, to monitor conditions within the unit, establishing abuse and neglect reporting training, increasing Choate’s security and professional staff, and installing surveillance cameras – something the OIG has called more than 20 times in the last five years. (This week, the IDHS spokesman said the department has 39 cameras and plans to install them this month.)
Despite the OIG’s call for more serious penalties for staff who obstruct abuse investigations, the report did not issue more serious findings against the psychiatric technicians for barring those staff from seeking employment at another healthcare facility, such as a hospital or nursing home, or veterans home.
State law requires the OIG to report the names of all employees it cites for abuse or “egregious neglect” to the Illinois Department of Public Health’s Health Care Worker Registry. According to this law, all are reported to the register, but the others are not.
Stacey Aschemann, vice president at Equip for Equality, said the fact that these workers are not prohibited from future employment with vulnerable populations is “very disturbing”. Peter Neumer, inspector general of IDHS, said it was his office’s general policy not to comment on specific details of its investigations or decision-making process.
Aschemann, an attorney, said the report shows that the OIG feels constrained by current regulatory language. The report found that the behavior of the workers who witnessed the abuse was “deeply disturbing” 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’ failure to report the abuse did not result in the patient’s death or serious deterioration in his physical condition.
Although he declined to comment directly on the case, Neumer signaled that legislative action may be needed. “OIG,” he said, “is willing to collaborate and advocate for policy changes to further discourage employees from engaging in behaviors such as the ‘code of silence’.”
Aschemann was more direct, saying that Illinois lawmakers should address deficiencies in the statutes governing standards of conduct for direct carers.
“It is clear that laws need to be updated to both provide harsher penalties for this misconduct and to ensure that employees who turn a blind eye to the well-being of the people they are paid to serve are reported to the Illinois Health Care Worker Registry are considered ineligible to work in the healthcare sector,” she said.