This article was produced for ProPublica’s Local Reporting Network in partnership with Lee Enterprises, as well as Capitol News Illinois. Subscribe to Dispatches to get stories like this as soon as they’re published.
Several employees at the Choate Mental Health and Developmental Center attempted to cover up a brutal assault on a patient, according to a new report from the Illinois Department of Human Services’ Surveillance Office.
The IDHS Inspector General’s Office report says the “widespread attempt at a cover-up” around this incident points to a deep-rooted “code of silence” among some workers.
The OIG report follows a series of stories from Capitol News Illinois, Lee Enterprises Midwest and ProPublica exposing a culture of patient abuse and cover-up at the state-run facility in rural southern Illinois. Illinois that serves people with developmental disabilities, mental illnesses, or a combination of disorders. News agency reports detailed the beating of Blaine Reichard in December 2014 and attempts by staff to cover up the abuse; the series also showed how workers accused of abuse allegations rarely face serious consequences for their actions.
The OIG report, which comes nearly eight years after the attack on Reichard, echoes many of the findings of news organizations and calls on IDHS to do more to protect patient safety. News organizations had requested the report when it was finalized in September under 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 Reichard in a choke hold and punched him repeatedly in the face after the two argued , leaving the patient with two black eyes, a broken lip, and bruises to his face and upper body. The OIG also cited five mental health technicians for negligence after witnessing the abuse, but did not seek medical care for the patient or report the abuse to authorities, despite the fact that one of them later told authorities that it appeared Reichard had “gone”. three rounds with Mike Tyson.
But the OIG investigation showed that the problem was not limited to a few bad actors. Among the challenges investigators faced when called to the scene: One of the mental health techs initially lied to state police and said he was in the bathroom at the time of abuse. A governess told them that she had not seen blood in Reichard’s room, but later acknowledged that it was. A social worker who was romantically involved with Allen leaked information about the investigation to him. And a nurse and doctor made misleading statements about the extent of Reichard’s injuries, according to the OIG report.
This collusion led the Inspector General to find Choate himself negligent. The establishment, the OIG said, must be held accountable for “not preventing the establishment of a culture in which so many employees chose to protect their co-workers instead of protecting an abused individual and apparently felt comfortable doing so”.
The OIG report concluded: “That so many employees participated in covering up the abuse of [the patient] suggests that this type of conduct may be endemic to Choate. Earlier news agency reporting revealed credible abuse allegations in which the state’s attorney declined to press charges because he said employees would not cooperate in determining what happened.
The OIG report said it is “crucial” that when staff lie or withhold information in an investigation, they “suffer consequences for their actions” – and that one of the best ways to identify such plots is to use video footage. The watchdog recommended the installation of interior 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 beatings. In 2016, Allen was charged with assault and battery and intimidation, and three others – Curt Ellis, Eric Bittle and Justin Butler – were charged with obstruction of justice. All eventually accepted plea deals for reduced charges: Allen was convicted 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 held criminally responsible for abusing Reichard, and no one served any jail time.
News agency reports also showed that Allen continued to be paid for a full year after the attack, until he was criminally charged. He has been suspended without pay since then and resigned in early October, a department spokesperson said.
But the other three had never missed a state paycheck until they were suspended pending termination last week following the OIG report finding them negligent. The state has paid them, collectively, more than a million dollars since Reichard’s attack. Initially, they were assigned duties 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 who faced criminal charges, the report cited two other employees for negligence – Christopher Lingle and John “Mike” Dickerson; the report concluded that the two 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 dismissal. Dickerson worked at the facility until his retirement in 2017. In his last three years on the job, he mowed lawns in Choate.
In a statement, IDHS spokeswoman Marisa Kollias said all employees named in the report had either resigned or been suspended pending release following the conclusion of the OIG investigation into september. She had previously said IDHS could not take disciplinary action against employees until the OIG case was concluded. That investigation has been suspended for eight years pending the resolution of Allen’s lawsuit, which ended last December.
Allen could not be reached for comment. A spokesperson for the union that represents the other employees named in the case did not respond to an email requesting information about 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 via 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.” These changes include the arrival of Equip for Equality, a legal defense organization, to monitor conditions inside the unit, the introduction of training on reporting abuse and neglect, the strengthening Choate’s security and professional staff and installing security cameras – something the OIG has called for more than 20 times over the past five years. (This week, the IDHS spokesperson said the department has 39 cameras and plans to start installing them this month.)
Despite the OIG’s call for more severe consequences for employees who impede abuse investigations, the report refrained from issuing more serious findings against mental health technicians who allegedly barred such staff members. seek employment at another health care facility such as a hospital, nursing home or veterans home.
State law requires the OIG to report the names of all employees it cites for abuse or “gross negligence” to the Illinois Department of Public Health’s Healthcare Worker Registry. Under this law, Allen will be reported to the registry, but not the others.
Stacey Aschemann, vice president of Equip for Equality, said the fact that these workers are not barred from future employment with vulnerable populations is “very troubling.” Peter Neumer, Inspector General of IDHS, said his office’s general policy was not to comment on specific details of its investigations or decision-making process.
Aschemann, an attorney, said it’s clear from the report that the OIG felt constrained by current regulatory language. The report said the behavior of the workers who witnessed the abuse was “deeply disturbing” but did not meet the legal definition of “serious” because Allen, not the other technicians, was directly responsible for the injuries, and because 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 matter, Neumer signaled that legislative action may be needed. “The OIG,” he said, “stands ready to collaborate and advocate for policy changes to further deter employees from engaging in ‘code of silence’ type behavior.”
Aschemann was more blunt, saying Illinois lawmakers should address loopholes in laws governing standards of conduct for direct care workers.
“It is clear that the laws need to be updated to impose tougher penalties for this misconduct and to ensure that employees who turn a blind eye to the welfare of the people they are being paid for are reported to the workers’ register of Illinois Health as ineligible to work in health care facilities,” she said.
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