DDS report faults provider and charges cover-up in near-fatal, group home food aspiration case
(Update: The Essex County District Attorney’s Office confirmed this morning (October 26) that they have opened a criminal investigation into this matter.)
As The Salem News reported this morning (October 25), an investigation by the Department of Developmental Services of the near death of a developmentally disabled man who aspirated on a piece of cake in his group home concluded that seven employees of the private provider that operated the residence were at fault in the matter.
The scathing report, which is dated September 8, also stated that a high-level employee of the Beverly-based provider, Bass River, Inc., removed key records from the facility concerning the matter and instructed staff not to cooperate with the DDS investigation. The findings have reportedly led to a criminal investigation by the Essex County District Attorney’s Office.
The report was released by the Disabled Persons Protection Commission, an independent agency, which investigates abuse and neglect of disabled individuals, and which had referred the case to DDS to investigate.
In August, we first reported that the staff of the group home had failed to react for nearly a week after the 29-year-old man, Yianni Baglaneas, reportedly aspirated on a piece of birthday cake in the residence on April 9. He was admitted to Addison Gilbert Hospital in Gloucester in critical condition on April 15, and spent 11 days on a ventilator and a week in the Intensive Care Unit at Mass. General Hospital.
Aspirating or inhaling food into the lungs is a particularly serious danger among people with intellectual disabilities.
The DDS report did not identify the Bass River staff or other employees by name, but one of the individuals cited for abuse and neglect is believed to be the group home director, and another is the provider’s residential director who had authority over all of the agency’s group homes.
According to the report, the residential director acknowledged instructing staff of Yianni’s residence not to cooperate with the DDS investigation. The director also acknowledged removing records from the facility. The DDS investigator was subsequently unable to locate key records relating to Yianni’s care.
The DDS report stated that charges of abuse and mistreatment were substantiated in the case because the group home staff was negligent in failing to ensure that Yianni, who has Down Syndrome, regularly used a portable breathing mask at night called a CPAP (continuous positive airway pressure) machine. Based on the input of a medical expert, the report concluded that the failure to use the machine was the cause of the aspiration that led to Yianni’s near-fatal respiratory failure.
A group home staff member did bring Yianni to a nurse practitioner at Cape Ann Medical Center in Gloucester on April 13, four days after he aspirated on the cake. The nurse practitioner diagnosed Yianni’s condition as bronchitis and an upper-respiratory infection. She performed a nebulizer treatment on him and prescribed cough syrup and Mucinex and Robitussin, which are over-the-counter decongestants.
According to the DDS report, the nurse practitioner stated to the staff member that Yianni should be brought back if his condition worsened, but that Yianni was never brought back to the medical center.
The DDS report charged that the group home staff, including the house director, committed mistreatment for failing to ensure that Yianni received the prescribed decongestant medications. And the report charged that the house director committed mistreatment in failing to follow up on recommendations of Yianni’s day program staff on April 14 that the staff seek medical attention for him because he appeared to be very ill.
Yianni’s mother, Anna Eves, said she believes criminal charges should be filed in the case in light of the DDS report. “It’s easy for them (the provider and key staff) to abuse and neglect people in the shadows, and this needs to be brought out into the light of day,” she wrote in an email. “I have felt physically ill since reading this report and reading the absolute disregard for my son’s well being. I cannot believe I ever trusted them at all.”
The DDS report did not address the issue of possible criminal charges, but did recommend that DDS re-evaluate the group home’s license to continue to operate.
Yianni was actually taken to Addison Gilbert Hospital on April 15 by his mother, who had not seen him during the previous week. She met him at a Special Olympics track practice in Gloucester to which he had been brought by a staff member of his group home.
According to the DDS report, Yianni’s Special Olympics track coach stated that Yianni appeared to be extremely lethargic, coughing and having difficulty breathing. Yet no one from the group home informed either the coach or Yianni’s mother that Yianni was seriously ill.
That group home staff member told the investigator that Yianni had been taken to the track practice because the group home was closing for the weekend, and it did not matter how sick he was.
We do not think Yianni’s case is unique in Massachusetts. This morning, I sent an email to the House chair and Senate vice chair of the Children, Families, and Persons with Disabilities Committee, renewing a call we have made for a hearing into issues surrounding oversight of privatized human services. We have called for such hearings by the committee in the past, to no avail.
Alleged obstruction of the investigation
The DDS report described a number of instances of apparent obstruction of the DDS investigation of Yianni’s case.
According to the report, the Bass River residential director acknowledged to the investigator that she removed documents from the group home before the investigator could see them. She also acknowledged to the investigator in an initial statement that she had directed staff in the group home not to cooperate with the investigation. She later changed that statement, according to the report.
One witness told the investigator that he heard the residential director say to a staff member that “there will be consequences” if he cooperated with the investigation.
The report stated that records that could not be found or obtained by the investigator included daily and after-hours shift reports, emails from the time-frame in question, medication-related documents, Yianni’s ISP or care plan reports, and staffing schedules.
Failure to use the CPAP machine
According to the DDS report, Yianni has been diagnosed with sleep apnea, a potentially dangerous condition that is characterized by interrupted breathing during sleep.
The report concluded that seven employees of Bass River were negligent in failing to administer prescribed medication and to ensure that Yianni used his doctor-ordered CPAP machine, and that this failure directly contributed to his “serious, life-threatening medical condition.” That failure “more likely than not caused Yianni to aspirate while eating or sleeping, directly causing the aspiration pneumonia,” the report stated.
In a 180-day period between October 2016 and April, Yianni only used the CPAP mask on 36 days, or 20 percent of the time, according to the report.
The medical expert told the DDS investigator that without the nightly use of the CPAP machine, Yianni’s breathing would stop while he was sleeping, his heart rate would rise, and his red blood cell count would drop to levels that could be life threatening. In addition, this situation would have affected Yianni’s brain function negatively during his waking hours, causing him to have difficulty chewing and swallowing food and to aspirate on it.
The medical expert determined that Yianni could have either aspirated on food or fluids built up in his throat due to not using the CPAP machine. According to the expert, there is a direct link between sleep apnea and aspiration pneumonia when the apnea is not treated with a CPAP mask.
At least two Bass River employees stated that they were aware the staff were not making sure Yianni used the CPAP machine, but failed to do anything about it.
One staff member stated that on the night of April 9, when Yianni reportedly aspirated on the piece of cake, she had heard him wandering through the house, but she did not direct him back to bed. She also did not see to it that he was wearing the CPAP mask because she knew he would remove it, and therefore, she said, “‘I don’t bother.'”
The report stated that Yianni’s mother became aware that the CPAP machine was not being used based on an internal reporting chip in the machine. As a result, she emailed the Bass River residential director in March, requesting that the group staff make sure to use the machine each night.
The residential director at first told the DDS investigator that she was not aware that Yianni was not using the CPAP machine, but she did not deny that she received his mother’s email and acknowledged that she apparently neglected to follow up on the issue with the group home staff.
The house director acknowledged that she was contacted by an unidentified group home staff member that Yianni was not feeling well and was also told on April 14 by Yianni’s job coach that he appeared to be very ill that day, but she did not follow up with either of these notifications.
The house director also admitted that she falsely told Yianni’s mother on April 13 that Yianni was not ill, but only had allergies. She said that she misled Yianni’s mother about that because she had confused Yianni with another resident.
The report also stated that, according to the staff, the house director, was rarely present in the group home. She told the investigator that she was frequently out at the Bass River office and at meetings, but she was unable to list meetings that would have taken up that much of her time, according to the report.
The report stated that other troubling characteristics of the group home include the fact that none of the staff were scheduled to be awake at night even though Yianni, in particular, was known to wander around at night and to take food from the refrigerator.
In addition, staff who were trained in administering medications, stated that they were only part time and that it was not their responsibility to do so.
Today’s Salem News article noted that Yianni grew up in Rockport and “appeared to thrive and was well-known in the community.” The article stated that a 2005 story in The Gloucester Times described how he had obtained his first job, at Smith’s Hardware, “where he greeted customers with a firm handshake or high-five and sometimes, a hug.” He was later voted king of his high school prom.
As noted, Yianni’s case is not unique. Poor quality care is a serious problem throughout the DDS system, and Yianni’s case is further evidence of that. The Children and Families Committee needs to take the first step in bringing official scrutiny to this system and beginning to suggest needed improvements to it.
COFAR blog 
This is disgusting, glad they are finally exposed…
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With regards to this recent incident at the provider agency Bass River. This supports my advocacy that the Commonwealth should have a dedicated facility to educate and certify those individuals entering employment with all provider agencies across the state. After Cori checks are performed and potential candidates are cleared to work for any provider, they must go through a training program before they begin work, especially at a Day program or group home.
I have often experienced staff not only know how to cook and egg let alone know where the self cleaning oven button is located on a stove.
Seems harsh, but if provider agencies keep hiring folks at low wages, where they have to hold down other outside jobs we are never going to get ahead of the game, especially recruitment of staff who want to work with this population. College courses are not the only criteria needed to enter this tough field, Folks need hands on training and that is where a full time 30 day training program should be instituted to help those who want to continue on in the field working with our most venerable population, and it would help weed out those who may not be cut out to work with the disabled.
Parents, siblings and guardians must get more involved.
Drastic changes need to be done by DDS and our legislatures.
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wow what astory. that reinforces the need for st. operated homes with nursing on duty/ jw
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Somebody fell off a turnip truck. “Drastic changes need to be done by DDS and our legislatures”? Really? They are one and the same, the judge, jury and executioner. The Feds need to take over and the guardians and families need to know what’s really going on at DDS. The least of the problems is how to cook and egg or press a button.
How about training staff to clean up an incontinent person timely and properly to prevent skin breakdown and use proper and safe body mechanics to ensure the resident and workers safety? How about teaching the clueless about proper boundaries and also that when workers are on the clock they are there to work, not sleep, watch tv, play on their cell phones or rob time resources and steal from the residents? The Commonwealth slackers should not be teaching any classes, the classes should be outsourced. They are the biggest offenders who project blame onto other agencies when very serious human rights and deficient quality of care issues exist within their own organization.
DDS is a far worse offender than any of the vendor agencies they oversee and their workers are paid relatively we’ll. Furthermore, they don’t hold themselves or their employees accountable for the many deaths and injuries they are responsible for. The Commonwealth of Massachusetts doesn’t want to be in the business of running group homes and the more residents killed off that live in state run homes, the better off they are. (Saves $$$ and gets them out of their obligations to families, especially those formally institutionalized)
There are some horrendous situations that have been allowed to exist with Management well aware of what is going on. While there are some excellent house managers, particularly on the North Shore, there are also some houses like the one at Carter Lane in Danvers where all workers should either be fired or transferred to break up the ‘organized crime’ environment that has been allowed to exist at that location. The house manager is clueless and lazy and one of the supervisors is mentally unstable and recovering from a substance abuse problem. Neither of these two people with supervisory responsibility should be allowed to remain in any capacity in this group home. Both have diminished capabilities to make rational decisions yet those sitting in offices in Hawthorne who are well aware and have been endlessly provided with proof turn a blind eye. Two drama queens who consistently perform under minimal standards.
How many times does someone from Hawthorne have to find unreconciled bank statements and missing receipts before a house manager is removed from their position?
How many times can the head nurse and regional director look the other way when Controlled Substance Logs are messed up and the house manager who has been trained and is responsible to assist in root causing issues and correcting them to ensure that narcotics aren’t being diverted just shrugs her shoulder and leaves for the day? Apparently the “boss” is the only one with responsibility that is exempt from mandatory overtime. God forbid she spend 5 extra minutes at work, especially after spending the day drinking coffee, smoking cigarettes, socializing and tending to her personal paperwork.
A resident who passed away in December of 2016 from aspiration pneumonia was fed the wrong texture of food which was prepared weekly by the House Manager herself. This went on for more than 8 months of the 12 that the resident lived in this particular facility. Doctor’s orders and established protocols were consistently ignored by the house manager and PCA’s. If a nurse brought the seriousness of this issue up to the house manager or a supervisor they would be bullied and mobbed. The resident was to remain upright for 90 minutes after eating, yet the workers would put this resident to bed (so they could go sit in their cars and talk on their cell, or smoke cigarettes (or pot, yes, one workers used to get stoned on site) and nurses would find her lying in her own vomit. When brought to the house manager’s attention she would say “Oh well, it happens”. Time and again Management sitting in Hawthorne were warned, and that includes the head of Nursing, and absolutely nothing was done. Numerous nurses on all levels reported the problems and not one Manager acted to correct the issue. Dozens of written emails and many proactive discussions took place because nurses marched into the offices of managers and directors as well as the head of Nursing, yet not one acted to prevent this situation or many others that have been reported. Oh, but Kathy and Scotty make sure they show up when the resident is at death’s door. Photo Op with the family. They don’t give a rat’s xxs. They just care about their next promotion.
The situation with these union employees is totally unacceptable. First off, there are a few already living off the tit of the taxpayers. Quite a few live in Section 8 Housing, AND are on Masshealth and brag about it. Yes, at least four workers at this house. (Why isn’t a cross check done by the state?) These same workers go running to the union when they get caught sleeping on the job, yet they never sign up for health insurance offered by their employer, the State of Massachusetts (Oh, and the night employees sleep on the job, every night. One big guy everyone is afraid of even shows up in his pj’s and bath sandals. They violate every possible rule yet when caught they run to the union and file a grievance and there are so many of those that the union is backlogged and can’t get to genuine issues.)
Just a few examples out of dozens:
How many employers allow you to show up for work late, then leave for an extended period of time for a Dunkin Donuts run as soon as your body walks through the door?
How about the serious abuses masked under FMLA? One of the biggest scams is to sign up for FMLA with every possible excuse only so it allows for an additional option to abuse the system. Liberal sick time and PTO perks aren’t enough.
Where else can you leave early and get paid for it? Sure, they get caught and just do it again or Management transfers them to another house or facility like Hogan.
How about spending days sitting on your rear, with your laptop open, or your face in your cell phone or a book or watching what YOU want on TV?
How about doing your laundry and mending at work?
How about stealing the resident’s food bought with their food stamps?
How about not dating opened food, and potentially feeding moldy or spoiled applesauce and broth to resident’s with their medications?
How about filling up your car or your boyfriends with the state credit card?
How about the endless bullying and mobbing that occurs when a concerned worker speaks up about urgent matters such as textures of diets for residents or the fact that another resident has skin breakdown because he is not turned on schedule (particularly because the night crew sleeps) and how he gets UTI’s and is hospitalized frequently most likely because he often has a decreased urine output due to the fact that he is not hydrated because he is not being given the proper water flushes via tube feeding as scheduled? Oh and he too will experience an early death because the slacker workers have created so many inpatient hospital stays that he has picked up cDiff and MRSA and antibiotics no longer work because he has built up a resistance. Even specially formulated combinations have no affect and the resident now harbors a low grade infection that will never go away. Eventually this will overrun his already compromised system and kill him long before the time he would have had if he received proper care.
How about the fact that records are falsified by staff who often fills out notes and medication records at the start of the shift so they can slack for the last 7 hours of work?
How about the fact that not following doctor’s orders is a violation of the law, and care is not provided by (non nursing staff) properly? In fact, how about a house manager who throws away a doctor’s Rx for a consult (more than twice) because SHE doesn’t think the resident needs the consult and she takes treatment into her own hands?
How about all that ‘cultural diversity’ that is shoved down your throat when you as a Caucasian are the minority? Yes, it’s great to have workers who typically don’t care about the residents try out homemade treatments from “their country”, ignoring doctor’s orders and the request by a licensed nurse that they refrain from ‘treating’ the resident.
How about lying to families, from top management to the workers? One mother calls every morning to check on her son, who is often not fed and lying across the sofa sleeping. They kiss up to her on the phone and she thinks all is great. If she only knew that every night workers camp out on the loveseat in her son’s room to sleep, and that they leave him unattended in the bathroom.
How about if a licensed professional nurse brings a serious issue to the house manager’s attention or has to escalate because she is too incompetent to carry out her duties and the worker doing the right thing experiences endless performance warnings that fill up their employment file and horrible reviews as “punishment” for speaking up and advocating for the resident?
And why does management allow this bullying and mobbing to occur? Three out of four workers at this residence in Danvers are lazy and entitled and they all cover for one another. It starts with the clueless house manager who is more concerned about her coffee, cigarettes and talking to her daughters all day (she acts on the ball only when resident’s family is present). The supervisors take off and do their personal shopping, in fact one who should not be setting foot on the property since transferring out would not turn in grocery store slips and got away with this for years. Guess what she was buying? Oh, and while on duty she would buy herself high end yogurts and special foods for her ‘diet’ and feed the residents low end brands, all at their expense. And the pot of oatmeal heated day after day-sinful. At least one-third of the time the residents don’t eat a proper breakfast anyway because staff is too busy making their own (from the house manager and downward, it’s all about their needs and wants first, not the residents).
How about the full time workers who already have another full time job and show up just to collect a check? There’s LOTS of that happening.
How about the little clique crowd created by the supervisors and their favorites who withold information from those who properly do their job as a form of punishment? How can a worker be written up for meetings not attended when they were never informed about the meeting or time change? Oh, it’s all part of the punishment blame game to protect the lazy, incompetent and coasters waiting on retirement benefits.
How about breaking every rule in the Employee Manual and having Management look the other way? Boundary violations occur, from verbally and physical abuse of residents to photographing them. Oh and the former Northeast Region Director who showed up when a patient was knocking on death’s door (as she was leaving for retirement) was told repeatedly by a mentally unstable supervisor that “she had better pictures on her personal cell for the obituary. Really? It’s a violation to take pictures of residents yet this supervisor “has thousands of them” and brags about it. The same supervisor who mocked the very patient she assisted in killing, and held her like a baby and asked other staff to take her picture for Facebook. Interesting that a nurse gets written up for taking a photo of a swollen ankle (for day to day comparison) but this supervisor who continuously violates every rule and displays an extreme sense of unprofessionalism on a daily basis can do whatever she wants be it photograph residents, treat them like babies or threaten to keep them from seeing their families or eating or being taken out for an activity.
It goes on and on. If you do your job correctly and do it well you will be set up to fail through collaborated lies. Supervisors will lie and say you didn’t respond to an emergency such as a seizure when they never called for you. And you being a good employee was elbow deep in cleaning someone’s fecal incontinence at the time all alone because the staff and shift supervisor were either off site stealing time or too busy with their own agendas. Interesting-medications in a locked room will suddenly be switched around hoping you’ll make an error that the crooked supervisors will lavish in embellishing. And perhaps the same day you will be bullied one on one by two supervisors with nobody else around and told you didn’t do something that really isn’t your job, but you worked your butt off doing things the night people didn’t do (because they slept all night) like laundry, stocking supplies, emptying trash full of urine and feeces
when you’re all alone on day shift and have a million other medical priorities to deal with. Even Senior Management will play games and use you when they need you or want 411, then start writing you up because they consider you a trouble maker or a whistleblower. (This is referred to as “having a target on your back”). You can be an excellent worker, but if there is any possibility of them or situations being exposed that cause manager’s issues they will try running you out of your job through endless lies. They are all out to protect each other. It’s absolutely surreal and so corrupt that just as occurs in school systems, the Feds should take over. But then again, in July of 2016 HHS found the Commonwealth’s group homes to be deficient yet it doesn’t appear any follow up has occurred with all the instability in DC.
These points have been made because DDS, of all government entities should not be penalizing any agency. Vendor homes and programs such as Bass River do a much better job than the Commonwealth does. Hopefully the media grabs hold of the issues along with the documented proof (photos and documents) of what has been outlined above in addition to so much more and exposes the real situation. Not only should these managers be fired and lose their pensions, but they as well as the lazy workers who have caused injury and death to residents should be held accountable and prosecuted.
DDS has been allowed to play judge and jury for too long. It’s all about burying the truth and protecting one another while coasting from paycheck to paycheck until it’s time to retire at the expense of vulnerable citizens; the developmentally disabled and the uninformed taxpayers. And if you think contacting the DA about possible charges against these employees would yield any result, think again. Maybe a 60 Minutes segment will wake up the public.
Pardon me, but until you’ve been forced to hospice a resident and witness their family’s pain and hear their weak cries as their body shuts down while well knowing that they are really dying due to neglect, being taught about cooking an egg and cleaning an oven just doesn’t matter. In fact I’d kinda say it illustrates part of the problem.
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It’s too bad you sensored the reply regarding DSS itself. This is the absolute truth. Although the response could have be written with more tact and more professionally the truth should be told. I witnessed one patient die and others injured. Also, how is their money being managed? One of the residents has a guardian who could care less. On his birthday the lazy house staff does absolutely nothing (I personally did). A dog and pony show is put on for residents with family, otherwise it’s an absolute disgrace. There is so much more that the public should be know about.
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