4 Deaths in D.C. Group Homes Raise Concerns About Neglect

The District government is failing to provide adequate care for mentally and physically disabled residents in its group homes, according to a court monitor who found that a pattern of neglect led to four deaths in the past year.

One woman and three men "are dead because they did not receive timely and competent health care," court monitor Elizabeth Jones said in a newly released report.

Jones expressed "grievous concerns" about the health and safety of hundreds of disabled people who live in the group homes, especially those with special health risks. The deaths, she warned, "reflect the lack of meaningful safeguards in the system."

The report did not identify the people who died or their caretakers. Jones attributed the deaths to serious neglect by two contractors that operate some of the homes and to shoddy oversight by the city, particularly case managers assigned to track the care of individual residents. Two of the people who died were in the same home.

The city, Jones said, has failed to penalize poorly run group homes.

The findings reflect long-standing concerns about the District's care of some of its most vulnerable residents. Mayor Anthony A. Williams (D) vowed to make reforms several years ago amid complaints about abuse and neglect.

The four deaths might have been prevented if the city's Mental Retardation and Developmental Disabilities Administration had followed up on recommendations for improving care in the homes -- and if the agency's case managers had been more vigilant in addressing critical problems, wrote Jones, whose staff reviewed medical records and death investigations.

The agency did not respond to a request seeking comment on the report.

The monitor reviewed the care of people deemed to be at risk. She found that health-risk management plans were out of date in 63 percent of the cases. In 61 percent of the case notes reviewed, residents had not received eight visits a year by their case managers, as the city requires.

The deaths Jones cited in her report occurred between November 2004 and September. She described numerous problems, including the failure to monitor diet and nutritional care; poor communication between group home operators and hospitals; delays in treatment because a person who died did not have a legally appointed guardian; and the failure of the mental retardation agency and the group home operator to check the qualifications of the staff at the home.

One of the deceased, Jones said, had been identified as having a high health risk. "Nevertheless, there was an extraordinary lack of vigilance about his care and treatment," she said. And although the home where he lived has since been closed, "there have been no sanctions against this provider, nor were there actions taken to ensure that the staff involved did not continue to work with other individuals at risk."

The report was filed Nov. 3 as part of Jones's quarterly review in a nearly 30-year-old lawsuit against the District that centers on the quality of care for the mentally retarded, many of whom also have severe physical disabilities.