Note: When this report was originally published, we were known as Protection & Advocacy, Inc. (PAI). In October 2008, we changed our name from PAI to Disability Rights California.

Health and Safety Risk at Agnews Developmental Center

A Preliminary Review of Incidents Involving Resident Access to Hazardous Materials

Disability Rights California

1831 K Street, Sacramento, California 95811

Gretchen M. Van Dusen, Investigator

November 1992

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This report presents the results of Protection and Advocacy Incorporated's (PAI's) preliminary review of incidents involving resident access to hazardous materials at Agnews Developmental Center (ADC). This review was undertaken as part of PAI's responsibility pursuant to federal and state mandates to investigate incidents of abuse or neglect of persons with developmental or mental disabilities when such incidents are reported or if there is probable cause to believe such incidents have occurred.

PAI reviewed five separate incidents involving resident exposure to hazardous materials that occurred over a 28 month period. Each of these incidents shared the following common characteristics:

PAI recommends that all incidents of resident exposure to hazardous materials be reviewed thoroughly and more effective procedures implemented to prevent further occurrences.

PAI's preliminary review has included the following:

This report is divided into four sections. The first section will identify the nature of the problem and applicable policies, standards, and practices. The second section will summarize each of the five incidents. The last two sections discuss the problem briefly and make recommendations.

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Policies and Practices

Agnews Developmental Center, operated by DDS, is a two-campus general acute and intermediate care facility serving persons with developmental disabilities. The East campus is located off Zanker Road between Highway 237 and Montague Expressway in the city of San Jose; the West campus is located in the city of Santa Clara off of Montague Expressway. Programs 1-5 are located on the East campus and Programs 6 and 7 are on the West campus. There are approximately 1,000 individuals served at ADC by a staff of approximately 2,000.

One of the goals stated in ADC's Mission Statement (Administrative Directive #10-A-1) is: "The center shall provide and maintain quality services in a safe, healthy environment that ensures the protection of individuals from harm, neglect and abuse." A preliminary review of incidents involving resident exposure to hazardous materials indicates that a safe, healthy environment has not been adequately maintained at ADC. More effective safety measures are called for to protect residents with pica behavior from hazardous materials.

The following ADC policies and procedures pertain to the maintenance of a safe and healthy environment for individuals served:

Administrative Directive #30-A-2: "Center Health and Safety Program"

Administrative Directive #30-A-3: "Safe Practices Committee"

Administrative Directive #30-A-12: "Safety of Individuals While on Grounds"

Administrative Directive #30-A-13: "Residence Environmental Safety/Procedure for Search"

Administrative Directive #30-A-14: "Safety Precautions on Outings"

Nursing Procedure #25: "Poisoning, What to Do".

These policies assign responsibility for the prevention and control of injuries to individuals served, delineate the process for regular review of occurrences and improvement in practices, and identify procedures for the proper storage of hazardous substances and recognition of the signs of poisoning.

ADC's policies and procedures refer to ACDD's Standards and Interpretation Guidelines for Services for People with Developmental Disabilities. Standard #768 (641) states: "Active attention is directed to avoiding hazards to the individuals served, such as dangerous substances, sharp objects, unprotected electrical outlets, slippery floors or stairs, exposed heating devices, scalding water, and broken glass. However, individuals should be prepared for and progressively exposed to routine risks that they are likely to encounter in normal environments."

Pica Behaviors

The DSM-III-R, describes pica as: "...the persistent eating of a nonnutritive substance...Mental retardation, neglect, and poor supervision may be predisposing factors..."

In a study of 806 institutionalized adults with mental retardation, 15.5% exhibited pica. The authors stated that pica is one of the most frequently observed behaviors among people with mental retardation, citing prevalence estimates from previous studies ranging from 25.8% to 3%. [Lofts, Schoeder and Maier, "Effects of Serum Zinc Supplementation on Pica Behavior of Persons with Mental Retardation" (July 1990) 95 American Journal of Mental Retardation.]

Three out of 94 deaths over a four year period at an institution similar to ADC were determined to be closely associated to pica behaviors. The author concluded that "the habit of pica constitutes a cause of considerable morbidity and mortality in certain institutionalized patients." [McLoughlin, "Pica as a Cause of Death in Three Mentally Handicapped Men" (June 1988) 152 British Journal of Psychiatry.]

In a study of accidental toxicological exposures in health care facilities that were reported to poison control centers, the largest proportion of mishaps (54%) involved "proximity of potentially harmful substances to confused persons." [Scalise, Harchelroad and Krenzelok, "Poison Center Utilization in Nosocomial Toxicologic Exposures: A Prospective Study (Dec. 1989) 31 Veterinary and Human Toxicology.]

Residents at Agnews Developmental Center are at high risk for injury due to their proclivity for pica behaviors.

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What follows are summaries of incidents that occurred within a 28 month period at ADC. The result of such incidents ranged from no observable injury to death. These incidents came to the attention of PAI during the course of other investigations and thus may not include all pica incidents at ADC during the identified period.

9/16/92 - (DHS L&C Complaint #07-05821 - citation anticipated)

28 year old male resident on East campus died after choking on a rubber glove that he obtained from a housekeeping cart containing cleaning supplies and a bag of latex gloves. Resident was discovered by housekeeper who observed him clutching his throat, walking down the hallway of the unit where he lived, and turning blue. The housekeeper reported that she had seen him roaming up and down the hallway as she was cleaning rooms.

2/25/91 - DHS L&C Complaint #07-04654 - Class A Citation

27 year old male resident entered kitchen area while attending classes on the West campus, pulled out plastic tube connected to a five gallon drum of Detergent 4000 liquid dishwasher solution, and sustained second and third degree burns to face, arm, buttock, and foot which required prolonged treatment at Valley Medical Center Burn Unit and physical therapy.

11/20/90 - DHS L&C Complaint #07-04372 - Class A Citation

28 year old male resident died after ingesting caustic laundry detergent from a drinking cup that was left in the laundry room of the unit where he lived. Injuries included extensive facial burns, involving the eyes and cornea, all the way down to the larynx, trachea, and mid-portion of the esophagus. Cause of death was attributed to "acute chemical pneumonitis by corrosive substance."

7/18/90 - DHS L&C Complaint #07-04088 - Class B Citation

18 year old resident ingested up to 51 tablets from vitamin packets stored in an unlocked employee locker after jumping over a station wall and entering a staff restroom. Seven days after the incident a DHS L&C evaluator entered the unlocked staff restroom and found four unlocked lockers which contained aspirin and a quart of liquid cleaner, deodorizer, and sanitizer.

5/2/90 - ADC Special Incident Report from Residence 636

27 year old female resident among a group listening to music in the residence backyard was observed eating a dead bird. After a struggle to have resident relinquish the dead bird, resident's hands and mouth were washed out with hydrogen peroxide solution. No observable injury was noted. Upon further search of the residence backyard, another dead bird was found.

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These examples of resident exposure to hazardous materials shared the following common characteristics:

PAI was unable to locate any ADC or DDS policy that addressed the prevention of resident injury due to pica behavior specifically. Out of 15 Administrative Directives relating to health and safety at ADC, only five could be found that addressed the need to prevent and respond to injuries of individuals served. ADC's Comprehensive Plan for Client Services, while acknowledging the need for reduction and prevention of client safety hazards relating to physical plant and sanitation, does not address resident exposure to hazardous materials specifically.

Although pica appears to be a relatively common behavior among ADC residents, sufficient measures have not been taken to ensure a safe, healthy environment for residents with pica behaviors at ADC.

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1) Thorough identification, tracking, and review of all incidents involving resident exposure to hazardous materials.

2) Modification of resident treatment plans to ensure the development and implementation of appropriate plans for addressing pica behaviors.

3) More focused attention by the Safe Practices Committee to ensure that resident exposure to hazardous materials is addressed effectively, including thorough review and analysis of incidents and development of preventive measures.

4) Thorough review of ADC and DDS policies by a pica expert to ensure appropriate policy revision and implementation.

5) Increased training of all staff regarding the importance of safely storing hazardous materials and properly supervising residents in order to maintain a safe and healthy environment.

6) Training of all residents to identify and avoid routine risks that they are likely to encounter in their environments.

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PAI #7002.01