08/24/2012 06:50 pm ET Updated Oct 24, 2012

Sonoma Developmental Center Slammed In New Report

This article comes to us courtesy of California Watch.

By Ryan Gabrielson

California's largest institution for the developmentally disabled risks losing millions of dollars in federal funding because of poor medical care and widespread failures to prevent abuse and thoroughly investigate when patients are harmed, state officials said in a confidential report.

The Department of Public Health inspection report presented a damning indictment of the Sonoma Developmental Center, which houses more than 500 people with cerebral palsy and other intellectual disabilities. Normally such reports are kept from the public, but California Watch obtained a copy of the 495-page document this week.

"Individuals have been abused, neglected, and otherwise mistreated and the facility has not taken steps to protect individuals and prevent reoccurrence," the report said. "Individuals were subjected to the use of drugs or restraints without justification. Individual freedoms have been denied or restricted without justification."

According to the report, the board-and-care institution must immediately upgrade patient care and abuse investigations to keep its federal certification. Without federal approval, the Sonoma center would lose reimbursement from the Medicare and Medicaid programs - crippling its budget and placing an even greater burden on the state.

For the Sonoma center, the penalty would cut off reimbursements that cover about half of its $160 million annual budget. Finance records show that the Medi-Cal program pays more than $6 million a month for patient care at the Sonoma center.

State regulators repeatedly faulted the in-house police force, the Office of Protective Services, for inadequate investigations.

"The facility failed to ensure evidence that all alleged violations and injuries of unknown origin were thoroughly investigated," the report said. The investigations "lacked significant and/or pertinent information to minimize recurrence."

"It leads one to believe that, in certain circumstances, it's a lawless environment," state Sen. Mark Leno, D-San Francisco, said of the inspection report.

In a series of stories this year, California Watch has reported that detectives and patrol officers at the institutions routinely fail to conduct basic police work, even when patients die under mysterious circumstances. In case after case, detectives and officers have delayed interviews with witnesses or suspects - if they have conducted interviews at all.

The force has also waited too long to collect evidence or secure crime scenes and has been accused of going easy on co-workers who care for the disabled.

The state Department of Developmental Services operates five centers that house nearly 1,700 patients with cerebral palsy and other intellectual disabilities in Sonoma, Tulare, Los Angeles, Orange and Riverside counties. California is budgeted to spend about $314,000 this year per developmental center patient.

Terri Delgadillo, director of the Department of Developmental Services, said the department "recognizes the action necessary to ensure the health and safety of residents at the Sonoma Developmental Center."

"Several key changes have already been made but more must be done," Delgadillo said in a statement. "Both the executive director and the clinical director have been replaced. Several other employees have been terminated or disciplined and investigations continue which could result in additional actions."

The report includes the Sonoma center's plans to correct its violations, which include hiring additional caregivers and retraining employees.

Regulators have not decertified a center for more than a decade. The state Department of Public Health, which licenses and regulates the institutions, decertified the Agnews Developmental Center in San Jose for patient neglect in 1999. Agnews closed two years ago.

In September, someone assaulted a dozen patients with a stun gun, an incident first reported by California Watch last month. The victims suffered severe burns on their backs, buttocks, arms and legs.

The Office of Protective Services received a tip that a caregiver named Archie Millora had abused patients during his shifts. Officers found a Taser in Millora's car, along with a loaded handgun, but did not make an arrest in the assaults.

Detectives continued to delay or overlook abuse cases in recent months, according to the report.

On May 25, Rue Denoncourt, a psychiatric technician, took a female patient into a bathroom and exposed his genitals. Another employee reported the abuse and the Sonoma County Sheriff's Department arrested Denoncourt for lewd conduct; he pleaded no contest earlier this month and was sentenced to eight months in prison.

The Office of Protective Services waited weeks to review patient records to determine whether others living on the unit where Denoncourt worked showed signs of abuse, the report shows.

In fact, there was another victim.

Denoncourt, who worked at the center 27 years, admitted to sheriff's deputies that he had also abused the victim's roommate, forcing the second female patient to touch him while he masturbated, the report said.

Three weeks earlier, on May 4, caregivers discovered bruises on both women, including an injury to a patient's left breast. State regulators found records showing the patients had not attended a Cinco de Mayo event at the center the previous evening and that Denoncourt was working on their unit at the time.

But the Office of Protective Services did not investigate whether Denoncourt was alone with the victims, according to the report.

The state Assembly yesterday unanimously approved legislation, SB 1051, to require the centers to report certain abuse and injury cases to outside law enforcement and advocacy organizations for the disabled. The bill, which now goes to Gov. Jerry Brown, also sets minimum qualifications for the Office of Protective Services' chief.

Leno has sponsored legislation, SB 1522, to mandate that centers notify outside law enforcement in cases of patient death, sexual abuse, and assaults with a deadly weapon or severe injury, and unexplained broken bones. The state Assembly is expected to vote on SB 1522 today.

The Sonoma center's nursing services were also faulted, most notably for unsafe practices when placing feeding tubes and failure to follow policies regarding how to read vital signs and assess patients' pain.

As part of the improvements, the report said center employees would receive training on an array of issues. One of them is handling of patients with pica, a disorder that causes people to ingest things that are not food.

On Nov. 22, patient Jean Erquiaga consumed part of a "soft knit shirt," according to an internal incident report. Erquiaga had long been diagnosed with pica, swallowing disposable diapers in years past, a concern caregivers were aware of.

Erquiaga began vomiting and, five days after eating the fabric, the center took the patient to Sonoma Valley Hospital, the internal record shows. Doctors operated on Erquiaga to remove material that had formed a bowel blockage.

Sonoma center records show Erquiaga died of respiratory failure on Dec. 1.

The Office of Protective Services opened an investigation nearly six weeks later, on Jan. 13. If center detectives intended to investigate potential criminal negligence, the caregiver responsible for protecting Erquiaga was already gone, the records show.

"This individual had been working towards transferring to Coalinga (State Hospital)," a Sonoma administrator wrote, "and is now employed there."

Ryan Gabrielson is an investigative reporter for California Watch, a project of the nonprofit Center for Investigative Reporting. Find more California Watch stories here.