Group Home Provider, City Sued Over Fatality

Months before Melonie Nelson choked to death on a mouthful of bologna, her caretakers documented her growing habit of devouring large quantities of food. Although one-on-one supervision had been ordered, on three occasions in the final 16 days of her life, Nelson managed to grab food from the refrigerator in the Northeast Washington group home where she lived and shove it into her mouth.

Nelson's death Oct. 30 is one of 23 that have occurred in a seven-month period, from Oct. 1 through April 30, in the District's long-troubled system of group homes for the mentally retarded, according to the advocacy group Quality Trust. Nelson is the first to be identified publicly. On May 11, in D.C. Superior Court, her mother, Marie Saunders, filed suit against the District and the group home provider, D.C. Health Care Inc., claiming wrongful death, gross negligence and fraud.

The $15 million lawsuit, first reported in Legal Times, comes as Mayor Adrian M. Fenty's administration promises a dramatic overhaul of the agency that supervises care of the city's developmentally disabled. Peter Nickles, Fenty's general counsel, said that Nelson's death and the 22 others are being investigated by an independent firm. The District does not release the names of the deceased for privacy reasons.

"This is a lawsuit and obviously is reflective of the strong position taken by the plaintiffs," Nickles said. "All I can say is we have committed to a reform plan."

Saunders said the changes come too late for her 41-year-old daughter, a "happy-go-lucky" woman who loved to dance, listen to music and collect medals for her athletic feats at the Special Olympics. A resident of D.C. group homes for 20 years, she had lived at the final one, at 4919 N. Capitol St. NE, since 2003.

"I called her every evening, and she would always ask me, 'When are you going to come get me out of this place?' " said Saunders, 69, a Northeast resident, in an interview at her attorneys' office. "This has been a time of anguish for me."

The recent group home deaths have raised concerns in federal court, where a lawsuit against the District on behalf of 650 developmentally disabled residents has continued for more than three decades. Advocates for the disabled said there are about 30 deaths a year in group homes, many from natural causes. Nickles said the recent deaths should not be "sensationalized."

"Each death has to be looked at on the basis of the facts," he said. "I think it's wrong to conclude that because someone has died there has been some impropriety. . . . A lot of these folks are older folks."

But Nelson did not fall into that category, said Sidney Schupak, one of Saunders's attorneys, and the circumstances surrounding her death reflect the failings of a system meant to protect her.

"We think a bright light should be shined on this whole issue," he said. "Enough with secrecy, enough people dying without a voice, enough anonymity. We need this to change."

The morning Nelson died, her group home was staffed with two of the three attendants required for the six female residents, according to an investigation by University Legal Services, an advocacy group representing plaintiffs in the federal lawsuit. The group, which routinely investigates unusual deaths at D.C. group homes, gave a copy of its report to Saunders, the D.C. government and D.C. Health Care Inc., a firm that operates 13 group homes in the District. The report, which figures prominently in Saunders's lawsuit, concluded that although D.C. Health Care "was well aware of Ms. Nelson's risk factors for choking on food . . . adequate monitoring and supervision was not provided on the day of her death."

A later addition to the report stated that the staff did not adequately clear Nelson's airway and did not perform CPR. According to the report, emergency medical technicians said they spent the ride to Washington Hospital Center "pulling meat" from Nelson's mouth. The owners of D.C. Health Care Inc., Babu and Gracy Stephen, did not respond to requests for an interview. According to Saunders's lawsuit, Marshila Davis, who worked at another D.C. Health Care facility, said company officials told her to "falsely tell investigators that she was the third person scheduled to work" at Nelson's group home that day.

"They lied and said I had had car trouble," said Davis, a three-year employee who has been suspended without pay since November. She said she told Saunders and her attorneys about the incident because she felt "it was the right thing to do." Saunders said she wishes she had never had to put her daughter in a group home. But, she said, as Nelson got older, "I couldn't stop her from going places that were unsafe -- like riding the subway to the end of the line or riding the bus to the end of the line."

Nelson was enrolled in a day activities program and worked a few hours a day at a minimum-wage job, stuffing envelopes. Saunders said she became concerned that her daughter was heavily medicated, "and I fussed and I squawked" to her caretakers. She said she was told that Nelson needed the medicine to control her habit of pacing. The investigation by University Legal Services, however, showed that Nelson was receiving nine medications -- including an antidepressant, an anti-anxiety medication, two antipsychotic drugs and seizure medication -- and said that "side effects could have increased her risk of choking."

On the morning Nelson died, Saunders said she received a disturbing phone call at 8:45 a.m. from the group home manager, who asked if she was alone but would not say what was wrong. Saunders said she feared all day that her daughter had been struck by a car until three staff members came to her home at 4 p.m. to deliver the news of Nelson's death.

"They said she choked and they did everything to save her," Saunders said. "I just looked at them -- there was nothing for me to say."