The Echo

(Pardon the underline. Sometimes Echo has a mind of her own. Perhaps it's because she can see into the past or perhaps b/c her A.I. has achieved humanity.)

"Criminal background checks were not documented for all Bellwether staff..." 

And this is just another simply sad truth, another notch their belt for Bellwether and the organization from which it was borne, Advoserv and Au Clair.

There is a distinct difference from what Bellwether promised the State of New Jersey, it's residents with disabilities and the families who had cared for them the day their child received her first diagnosis. While stories of satisfaction do exist, Bellwether couldn't maintain the staffing to ensure quality in all of its 60 plus facilities.

On June 27th, the New Jersey Record revealed detailed confirmed accounts of abuse cited in State inspections and reviews of the companies community facilities. It was dark.
https://www.app.com/story/news/investigations/watchdog/2019/06/27/bellwether-behavioral-health-group-home-nj-failed-while-collecting-taxpayer-money/1582291001/?fbclid=IwAR0QUbZ74wl3Pe92Gii2EAWaR9-AOCtvbub-cl9E5WuzXbsb9epRt3S2Qsg

What follows is an abbreviated account of the violations documented and confirmed by reporters Kim Mullford, Gene Meyers, Lindy Washburn, and David M. Zimmer. Thank you for your thoroughness and attentiveness to the needs of those without a voice. 

The state found:

• In Susan's Osborne's chart, it was clearly indicated that her meals be cut into small bites and be observed by staff her during meals so that "she wouldn't stuff her mouth swallow too quickly." These were medical orders entered into Susan's care plan by HER DOCTOR. It didn't make sense that a staff member would neglect these orders. Nonetheless, Susan died May 30th after choking on her meal. It's alleged that three staff members immediately moved to cover-up the cause of her death. A lawsuit filed by Susan's guardians paints a grim picture of her death, the cover-up, and finally the admission from staff that they had not followed her doctor's orders. Bellwether is named in the suit; their response is to blame to the employees. BLAME THE EMPLOYEES? Bellwether hired the EMPLOYEES. Bellwether trained the EMPLOYEES. Susan's death is a shared preventable tragedy for which Bellwether should accept ownership of due to their failure to ensure her safety and care. 
• Joshua Hays was another resident in Susan's home. At 24, he was challenged by autism and pica. In 2016, Joshua needed surgery to remove indigestible items, including balloons and rubber gloves that he had eaten as a result of his pica. Bellwether, then known as Advoserv, assigned employees to the hospital to observe Joshua's recovery from surgery. During his first 36 hours under the oversight of his "observer," he removed and ingested his abdominal bandages. According to court records, the family settled its lawsuit for $575,000.
• In May 2017, Carlos Beltre died under what his family felt where mysterious circumstances. His sisters had noticed that Carlos often had injuries during visitation - a split lip, a black eye, and cuts that had been stitched at the hospital. On May 17, one of his sisters received a call that he had stopped breathing. His death certificate states he died from an irregular heartbeat of unknown cause - while in the direct sight of staff. The family is currently litigating the events that led to Carlos's death.
• A few days later, in another home, Francesca Gregorio, got up in the middle of the night in search of something to eat. The kitchen cabinets were supposed to be locked and Francesca was supposed to be supervised. However, she found an open cabinet and drank a bottle of oven cleaner. After the initial agony, she fell into a coma at the hospital. She's now a resident of a rehabilitation facility where she receives all of her nutrition through a feeding tube. She can no longer walk.
• In Gloucester County, Lauren Page was punched in the face by a staff member. She had to have surgery to repair her broken eye socket. The employee pled guilty to assault and was placed on 1 year probation. Lauren now suffers from PTSD. 
• Nicholas Mayer had autism. At a doctor's appointment with his mother, she notices scratches and similar injuries. Nicholas told her that they were from being restrained. When his mother investigated, she found the staff had a code word they used to get Nicholas worked up so that they could restrain him. She reported what she learned to the state. The state confirmed the assertion. 

This is what Bellwether advertised as their strength: Skimming the children and adults who received the higher rate of reimbursement because of the need to add additional staff to manage them. Only, the staff simply didn't exist. Yet, the homes had to operate. PEOPLE lived there. They were after all HOME to each of the residents. And despite Bellwether's demise, most residents will continue to call these facilities home as outside operators are moving to take over management and staffing of these homes. 

What no one has addressed is how to undue what happened to those residents who lived in facilities that repeatedly failed them. Or how to prevent it AGAIN. Florida, Delaware, New Jersey. 

The legacy continued. By year three Bellwether business in the Garden State was falling to pieces. 

NJ Doors Closed Tue, May 28, 2019 – A2 · Courier-Post (Camden, New Jersey) · Newspapers.com

Staff Shortage in New Jersey Tue, May 28, 2019 – A2 · Courier-Post (Camden, New Jersey) · Newspapers.com

I had planned to close this blog with a bio of each child or adult identified as dying while in Bellwether's care. When a hedge fund buys a for-profit mental health system, it inherits it's debts, losses, and deaths. The stain transfers one owner to another, although that does not exculpate Ken Mazik's role in the nightmare conditions of the beast he created and from which enriched himself.

Prince Jon was the first known death.

Paige Elizabeth Lunsford
Florida, July 6, 2013

On July 6, 2013, Paige Elizabeth Lunsford died while in the care of Carlton Palms. The story of her death would be recounted in the press multiple times. It was her death that might have put the wheels of closure in motion.

In the days prior to her death, Paige Lunsford vomited "like a waterfall" according to a supervisor at Carlton Palms where the 14 year old with autism resided.

Yet, Paige didn't receive proper medical care or the potentially live saving trek to the Emergency Room at her nearest hospital until she was dead. Her official cause of death was medical neglect and inadequate supervision. That's are far cry from what her death entailed.

"For five days and five nights, Paige Elizabeth Lunsford... wretched like a waterfall, could not eat, and thrashed about in an educational facility staffed with teachers, nurses, and doctors."

Paige's condition was not improving, yet no one called for help. Instead the young teen was placed in restraints, they bound her wrists, ankles, biceps, and waist to try to control her thrashing.  Ten days after Paige was admitted she died of a high fever. The coroner noted that she was severely dehydrated due to an infection - a condition that could have been treated and did not need to end in death. Where was the nurse? Where was the doctor? Why did no one come to Paige's aid as the young girl was strapped into a her death bed? Why did her parents not know how sick she was? They'd delivered a health teen just 10 days prior and Paige was a minor!

7/4/2019

One year ago, I put Echo Awareness into hibernation. I walked away. I needed a breather. Audrey Quinn's podcast on Bellwether and the developmental mental system had aired with accolades. I was tired. I was traumatized. I was fighting my own battle at home to regain my child with classic autism who had spiraled into a prolonged manic episode. She'd missed almost half a school year because she was unsafe to herself and others. She has a mean a left hook and phenomenal aim. We were desperate and searching for answers for her. We contemplated in-patient treatment, but there were no facilities in Delaware that had an autism unit. Our daughter would be placed with children who cut, who had eating disorders, who were rehabbing from drugs. All things a child with autism would learn without even trying to due to the nature of the condition. She'd be part of group therapy even though she was non-conversational with limited verbal and had slowed verbal processing. Essentially, she falls behind in conversations and when she does share she's usually several minutes behind and her vocabulary is limited. The one facility that evaluated her, the one with worst reputation but one of the only two in-state that treated children with mental and behavioral health needs, denied her admission. She needed more than they could provided. I was grateful. I didn't want to leave my beautiful daughter in place where there was no autism translator. While we were there a patient set a fire in the bathroom and the police came and put the facility on lock-down. We had to be escorted to our car by police.

With a new psychiatrist on-board, (we got booted mid-episode by the premier children's hospital in Delaware and Florida because her bipolar diagnosis came from an emergency room Psychiatrist in a Maryland hospital.) They lied to us about why they couldn't continue to provide her with behavioral health services. It wasn't that we missed appointments, we were dutiful. We weren't difficult parents. We followed instructions to a T. We were told that the hospital was restructuring its behavior health department to imbed pyschs on the units and they would have little time for out-patient visits. In April, we made the journey to the Mayo Clinic in Rochester Minnesota for a second opinion given she had several cases of altered mental status and seizure like behavior that resulted in ambulance transport from school to the same children's hospital that had dumped us. In May as I read the reports from our Mayo visit, I found the real reason. The hospital was upset that the bi-polar dx came from an ER doctor not their own - one in a small little facility that sat in the county seat of Cecil County, MD, 5 minutes from house, and where the last ICT escort took our family b/c we could not de-escalate our beautiful daughter from her dangerous episode.  The irony? Our children's hospital has contracted to operate the Pediatric unit at the hospital where we finally found the bipolar dx and where the doctor put his foot down and said no more speed. That doctor saved our lives. After a year, the contract was severed, and that smaller independent non-profit hospital is now merging with the largest healthcare system in Delaware. Guess that contract didn't work out. The  Mayo papers were "enlightening." In a time when there is a shortage of mental and behavioral health providers, where waits can be six months or more, hospitals are playing kick the can with our special children. Second opinions not welcome.

And from that moment, I knew I needed a break. That break has come to an end. There are some old Mazik oddities to tie ribbons around and the status of Bellwether in New Jersey desperately needs review because sometimes it's easier to watch children and adults die than it is to do YOUR JOB!