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State's mental health system fails
girl
February 10, 2007
By Eileen Nimm (For more
information,
Angellika "ANGIE"
Arndt's story
"Bubbles
in my Milk",and
more.)
 On
the outside, it looks like the story of a little girl’s traumatic
death in a treatment center last year will end with sentencing in
March of a social worker and the corporation for which he worked.
But an in-depth look into the
state’s review of practices at the Rice Lake Day Treatment Center
and interviews with those who still mourn for 7-year old Angellika
Arndt suggest that the story isn’t over by a long shot.
The Chronotype recently obtained a
copy of psychiatrist Randall Cullen’s full review of Arndt’s death.
That review paints a disturbing
portrait of management and staff who seriously violated the trust
put in them to care for children with emotional/behavioral
disorders.
Arndt, who was a client of the
center owned by Frederic-based Northwest Counseling and Guidance
Clinic, was placed in a prone control hold to subdue her behavior on
May 25.
But instead of slipping into sleep
as usual when the fight had left her, Arndt suffocated under the
pressure of the face-down hold administered by social worker Brad
Ridout.
Ridout, 29, of 20 E. Evans St.,
Rice Lake, faces sentencing in Barron County Circuit Court on
Friday, March 2 for misdemeanor negligent patient abuse. He faces up
to 9 months’ imprisonment and/or up to a $10,000 fine.
Northwest Counseling and Guidance
Clinic faces sentencing for homicide under the patient abuse
statute. The state plans to recommend the maximum penalty of
$100,000.
No other charges have been filed.
Although the Rice Lake center is
closed, the clinic continues to operate 12 more centers in northern
Wisconsin, which for some is cause for grave concern.
“The danger is that with the
sentencing some view the issue as resolved, but in a very real sense
it’s not over,” said Hugh Davis, executive director of Wisconsin
Family Ties in Madison.
Davis’ concern is tied to the
continued use in children’s day treatment centers across the state
of the face-down-on-the-floor hold that is used as a means to
control behavior.
“What’s being practiced regarding
the use of prone restraint in the clinic’s other facilities?” Davis
asked.
Children’s mental health day
treatment is governed by the state Department of Health and Family
Services. Each site is certified by the state and reviewed
regularly.
Following Arndt’s death, the state
authorized Cullen to investigate the practices of the Rice Lake
center and to issue a review.
Based on Cullen’s review, the state
issued a statement of deficiency listing multiple violations by
staff at the center and called for a plan of correction.
The clinic, with funding at the
Rice Lake center suspended by the state, submitted two plans of
correction, which the state rejected. Before the state could reject
a third plan, clinic president Denison Tucker announced that the
clinic would not re-open the Rice Lake center.
Criminal charges against the
corporation and Ridout followed.
Cullen’s review points to a number
of people whom he said failed Arndt in their clinical and medical
leadership.
According to the review, for the 1
short month that Arndt was a client at the center, an ill-prepared
staff struggled to gain control of her behavior but only succeeded,
with the use of control holds, in becoming more frustrated.
“It’s unconscionable that other
people were not held accountable,” Davis said.
“The problem with the corporation
being charged is that it provides anonymity for those who condone
the practice of prone restraint and for those who use it,” he said.
“They are all anonymous and free to
apply their trade wherever they go,” said Davis. “Do they still view
its use as viable or now inappropriate?”
Included in the federally mandated
state program of Disability Rights Wisconsin’s recommendations to
the Department of Justice was the inclusion of supervisory,
administrative and clinical staff in criminal charges arising from
Arndt’s death.
Who will take the children?
Arndt was born in Milwaukee and
became a ward of the state after her parents gave up their parental
rights.
She’d lived in more than one foster
home by the time she reached the home of Donna and Daniel Pavlik of
Ladysmith in early 2005. The Pavliks hoped to adopt Angellika, Davis
said.
Arndt was at first placed in a day
treatment program at Marriage and Family Services in Eau Claire.
Because the Pavliks wanted Arndt to be exposed to some academics
before she entered first grade in the fall of 2006, she was admitted
to the Rice Lake Day Treatment Center on April 24.
Northwest Counseling and Guidance
Clinic’s centers are certified to take only Level I clients, those
with conduct or oppositional disorders. Yet, according to Dr.
Cullen’s July 17 review, some 50% of the clinic’s clients had needs
beyond Level I. Arndt was one of those clients, Cullen said.
Arndt was diagnosed with reactive
attachment, anxiety and attention deficit disorders and an unnamed
mood disorder. There was also a long list of social-emotional and
behavioral concerns. Arndt was, as far as Cullen could tell, on five
or six different medications, the majority for psychiatric symptoms.
In his review, Cullen could not
find where that information was integrated into Arndt’s initial
assessment or treatment plan at the center.
Among other criticisms, Cullen
noted that there was no group process to discuss Arndt’s treatment
plan. “Clearly given these diagnoses, symptoms and meds, the client
was not appropriate for a Level I program,” Cullen wrote.
In an interview with clinic
executive director Jill Chafee, Chafee told Cullen that the clinic
was pressured by schools, county social workers, parents and
caretakers to take their children as clients.
Cullen confronted Chafee about the
wisdom of taking children who might be better served in a Level II
or III program. Chafee responded by asking, “Who would take the
clients as there are no alternatives?”
Tucker said shortly after Arndt’s
death that, “For children in northern Wisconsin, our day treatment
facilities are many times their only hope.” He said that in 2005,
the clinic provided care to more than 2,000 children.
Cullen wrote that a critical factor
in the urgency to take inappropriate clients could have been the
lack of funding for more suitable facilities.
Day treatment is fully funded by
Medical Assistance while hospitalization or residential treatment
would likely cost the referring county more, Cullen wrote. Still, he
wrote, “The Northwest programs have been too eager to acquiesce to
demands for service.”
‘A failure of treatment’
Center staff interviewed by Cullen
reported that the physical holds placed on Arndt were ineffective.
Ridout expressed his “persistent frustration” regarding Arndt’s need
for frequent holds and her poor response to the behavioral program.
“He wished they had other approaches to offer,” Cullen wrote.
Tucker reported shortly after
Arndt’s death that the prone control hold used at the clinic’s
centers is an emergency measure that involves placing the child face
down, and holding the child’s legs, arms and shoulders, but not the
chest, down to keep children from hurting themselves or others.
Standard practice for the length of
time a child should be in a control hold is 1 minute for every year
of the child’s age up to a 15-minute maximum, said Rick Pelishek,
who is Disability Rights of Wisconsin’s lead investigator into
Arndt’s death.
Cullen reported that Arndt was
placed in physical holds on April 24 for 97 minutes, on April 26 for
40 minutes, on April 27 for 17 minutes, on May 15 for 85 minutes, on
May 18 and 19, each for 25 minutes, on May 22 for 35 minutes, on May
24 for 98 minutes and on May 25 for 58 minutes.
Pelishek said his investigation
into Arndt’s death shows that she was placed in a control hold at
least once per day for a minimum of 15 minutes.
The use of restraint is allowed in
Wisconsin to ensure the safety of the child or others during an
emergency safety situation, according to state requirements.
An emergency safety situation is
defined as unanticipated behavior that places the child at serious
threat of violence or injury if no intervention occurs.
According to Cullen’s review, Arndt
was put into holds for standing up fast, turning quickly in an
aggressive manner, throwing herself back in her chair, refusing to
move, refusing to sit as told, putting her hands down the front of
her pants and kicking her shoe off her foot and across the room.
The state’s statement of deficiency
noted that none of the behaviors described in the clinical chart for
Arndt that led to control holds met the statutory definition of an
emergency.
“The unrealistic demands for total
body control, sitting perfectly still in a proscribed manner, seem
to invite oppositional behaviors,” Cullen wrote. He wrote that Arndt
would have likely settled on her own if there was an option to place
her in a time-out in a quiet, safe, padded and monitored room.
“Using prone restraint is viewed as
treatment, and it’s not,” said Davis. “It’s a failure of treatment.”
He said many of the children in the
treatment centers that are given control holds as a means of
subduing behavior have already been traumatized.
“You’re taking these kids and
trying to change them so they become productive members of society,
do you really do that by restraining them?” Davis asked. “Aggression
breeds aggression. The more you try to control someone, the more
resistance you will encounter.”
Case manager Erin Cater was holding
Arndt’s legs down during the fatal hold. She recalled lots of team
discussion regarding what to do with Arndt that would be more
effective to reduce the physical holds, Cullen wrote. “She was
frustrated about the lack of progress,” Cullen wrote of Cater.
Cullen wrote that clinic notes on
Arndt “seemed tragic in that the staff were clearly struggling to
deal more effectively with this failing client yet most discussions
were informal, documented informally after the fact and lacking
clinical and medical leadership to more urgently pursue a better
plan, gather information, make decisions.”
Cullen interviewed a number of
parents whose children were clients of the Rice Lake Day Treatment
Center.
One parent told him that she would
take her two foster children to a different program if one existed.
She said one of the children would have a “scar for life” from a rug
burn suffered when the child hit his head during a physical hold.
A caregiver said she thought kids
at the center “might be getting restrained for foolish purposes.”
Also disturbing is Cullen’s report
that internal operations manager Tim McIntyre, who “was not
specifically qualified as a trainer,” was responsible for training
the staff in the behavioral management program, which was used
across all Northwest Day Treatment sites.
McIntyre was scheduled to meet with
staff at the Rice Lake center to discuss Arndt’s frequent holds,
which he had been discussing with staff by phone. That meeting was
scheduled for the day after Arndt died.
Disability Rights of Wisconsin’s
recommendations to the state Department of Justice included banning
all forms of prone restraint in state regulations and by state
statute.
Negligent record keeping
Arndt’s initial assessment before
becoming a client at the Rice Lake Day Treatment Center took place
on April 11. Arndt was admitted on April 24. A report from her
initial assessment was not written until April 28.
“This would seem to indicate not
taking the assessment seriously or a haphazard review of the initial
assessment and possibly no actual meeting to discuss the
assessment,” Cullen wrote.
He wrote that a previous treatment
list for Arndt did not include the day treatment facility where she
reportedly did well in the summer of 2005.
Arndt was a client then in the
Marriage & Family Health Services Migisi Therapeutic Day Treatment
Program in Eau Claire.
An August newsletter from the
agency states that during her 8-week treatment program, Arndt was a
“very workable child” and never had to be restrained. “She had a
complex stress background and was a victim of abuse. Angie was a
good child who had bad things happen to her,” the newsletter stated.
According to Cullen’s review, Arndt
was on five or six medications. When interviewed by Cullen, Ridout
said he did not recall learning anything about the medications or
their side effects from program nurse Patricia Jordan.
A medication verification form
signed by Arndt’s pediatrician on March 22 said to contact
prescribing psychiatrist Rhonda Davis to review Arndt’s medications.
“Dr. Davis was finally contacted 60 days after this note was
signed,” Cullen wrote.
Notes from roughly April 24
indicate much staff debate and confusion about whether or not to use
the medication Guanfacine to help Arndt settle when agitated.
In his notes of Arndt’s initial
mental status exam, consulting psychologist Dr. David Swenson, of
Duluth, Minn., noted Arndt’s chronic daily headaches. Yet, there was
no reference to them in Arndt’s chart, including the treatment plan
or nursing notes until May 22, 3 days before Arndt lost
consciousness.
Cullen wrote that the side effects
of one medication, Propranolol, were lowered blood pressure and
pulse. He wrote that a sign of lowered blood pressure is often
headaches.
“When struggling in a physical hold
and under immense stress, did the Propranolol block her ability to
mobilize adrenalin and meet the demands on her heart rate and blood
pressure?” Cullen wrote. He wrote that Arndt’s vital signs should
have been monitored closely, especially around the times of the
physical holds.
“I believe the RN and the medical
director were negligent in monitoring this patient’s medications and
potential side effects as well as her well-being during extended
physical holds,” Cullen wrote.
He continued that Jordan and
Northwest’s medical director, identified only as Dr. A. in the
review, had a responsibility to Arndt and the staff to “aggressively
clarify these issues” and to “urgently communicate with the
prescribing psychiatrist, not haphazardly and lethargically while
the patient was failing for a month.”
In her interview, Jordan told
Cullen she was typically at the Rice Lake center 1 day per week for
about 7 hours. She said that was not enough time to review each
child’s medications. “She had not time to write any note or take
Arndt’s vital signs until about 1 month after Arndt’s admission,”
wrote Cullen.
He wrote that if the medical
director could not provide a more active clinical role in the
program “as medical directors do in other certified programs,
perhaps he should step away from that title.”
Finally, on-site administrator Lori
Czarneski’s clinic notes about ongoing discussions about Arndt’s
care weren’t written by her until June 28, over a month after
Arndt’s death, Cullen wrote.
by Eileen Nimm Chronotype staff
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