DEPARTMENT OF HUMAN SERVICES ACT 33 TEAM FATALIW REVIEW REPORT. :5 DAVID HESS Data of review meeting: 1119412016 Date of raped: 1Gi14i2516 Child?s names: David Hess Ir-ather?s name: ?1&6 fess: Path-?rs name: Address Sihiings: Aitagad perpetratcrs: Re?a?anship ta child: Residential Treatmant Staff (.7 MMAY On October 14, 2916, the Pennsyivania Department at Human servings (PA-OHS) received a Chiid Pmtectfve Services (CPS) report a?eging that David, a resident sf Academy?s residential treatmem pragmm, had died the day prior. it was reparted that David was restrained by staff a?er acting aggressivaw and destroying prepariy. Per the reparter. David hit his head during the resiraint. David was a resident cf Lebansn Cuunty at the time of h?s death. .3 maidentia? treatment fac??ty is ds?ned as a 24-hour iiving setting in which care is previded for one or mere ghiid?ran. Residen?a! facilities in Pennsyivania are ?censed and regviated by PA-EJHS. The PA-DHS Bureau 91' Human Servicas Licensing is far mg cf regvia?o?s related to the and their programs, Wor?awarth's ?cense was mast reaently renewed in August 2613. Faliawing David?s death: revoke? Wordsworth?s iicense and issued an ard?ar for an emargency cfesure. PA-BHS a?ciais remained on site at anti? ail resicfenis were relocated. The CPS raped was assigned to a PA-DHS program representative far inves?gatian? The assigned PA-DHS inves?gator. amther investigator. and the Of?ce cf Chitdren. Yauth. and Regianat Of?ce (OCYF-SERO) Director traveled ta Asademy ta beg?n the E?vestiga?an. They were provided with a safety ptan far the other regidents in the program. Three cf the alteged gerpetrators had been piaced an administrative leave pending {ha Gamma the investiga?an. The staff observed David?a room. The light ?xture was braken and there were :shards of giaas on the ?eet David's clothing had been pieced in trash DEPARTMENT OF HUMAN SERVICES ACT 33 TEAM FATALITY REVIEW REPORT- DAVID HESS bags. Wordsworth staff reported that had informed them that the room did not need to be kept secure. PA- DHS staif reviewed video footage of the night David died. The door to Qavid?s room was visibie in the footage. The PA?Di?is staff noted which Wordsworth staff persons and residents went into David's room and when they ieft The PA-DHS staff interviewed nine youths who iived on the same fioor as David. The youths provided various accounts of their observations. Cine sooth reported that he heard screaming and talking but that he couid not de?ne what he heard. He noted that did not iike David and atlaged that, during a restraint two weeks odor. took advantage of the situation and punched David in the chest. Another youth reported that had been upset with David since the start of the shift and that Wordsworth staff were beating on David prior to taking David into his room. A third youth reported that David had stoieri his iPod and that staff had gone into the roorn to retrieve the iPod. Two other youths noted that David had been put into restraints on two occasions that evening, the first of which occurred when staff went into David?s room to get the iPod. After staff left David?s room. there was a bang and the sound of giass breaking. Afterwards David was restrained a second time during which he couid be heard taunting staff and than later staff to get off of him because he could not breathe. Another youth reported that, one month prior, rhad hit David in the face during a restraint The remaining youths reported hearing hanging and the sound of breaking coming from David?s room. They stated that they saw a number of staff entering and exiting David?s room during the incident. The PA-OHS investigators interviewed three Wordsworth staff who had been invoivod in the incident. the floor supervisor, stated that. sometime before Stet) PM on the night of the incident, David stoie an iPod from another resident. . a residentiai yooth reported that he witnessed the youth enter David?s room, and an argument ensued regarding the stoien iPod. reported that he entered David's room with a therapeutic behavioral oounseior. and then escorted the other youth back to his own room. then questioned David about the iPod. David denied having the iPod. but' stated that thev were going to search the room. reported that he found the iPod and it was returned to its owner. .. stated that he then heard loud noises coming from David?s room. entered the room and placed David in a restraint because he was acting sggressiveiy. entered the room shortly thereafter. reported that he tried to speak with David, out David would not listen so staff ieit him alone in the room. stated that, a few minutes tater; he heard glass breaking and furniture being thrown in David's room? geooited that David had barricaded his door with furniture so he forced his way into the room with . Usvid was swinging, kicking. and breaking the ceiling tights. than dissed 'iltavid in a restraint. reported that. during the restraint, punched David in the ribs. reported that pot David in a headiooir. with his forearm on David's neck. stated that it seemed like David was not breathing so removed his arm. stated that vies gasping for air so he started chest compressions. Both caiied the staff nurse from i" sir personal teiephones. By the time a second caii was made to the nurse, spproximateiy two to three minutes after the restraint ended. David reportedly iost consciousness. denied that anyone had salted 91 1 at that time. . reported that he was trained in CPR but that he oniy did chest compressions. He eiieged that was also doing chest compressions but that. at one point, grew physicaiiy tired so he began doing chest compressions with his foot. reported that. when the nurse entered the room. sported that David hit his head. stated that he felt pressured to agree. but that he iater told notice that David had not hit his head, Thenurse checked for Gavid's pulse but could not ?nd it. The nurse caiied 911 stated that he beiievad David was dead and reported that first responders did not arrive until 3040 minutes after the nurse coiled 911. The PA-BHS investigators met with the Wordsworth {Director of Nursing and severai of the horses. The Director provided the PA-DHS staff with a copy of Wordsworth?s Emergency Medical Piano The oian provided direction for start. inciuding procedures for contacting onsits nursing staff and notifying the on-cail physician if an incident occurs after hours. The Pien aiso oisariy noted that, if there was a emergent situation. then 911 shouid be contacted. During a previous interview, the PA-Di-is investigators isarned that the first sail to the Wordsworth DEPARTMENT OF HUMAN SERVICES ACT 33 TEAM FATALITY REVIEW HESS nursing staff went unanswered. Neither the on-oaii physician nor the Wordsworth Medicai Director was contacted on the night of the incident. Nurse? was present on the night of the incident. She stated that she received the cart that David was in an Emergency Safety intervention. stated that she was administering medications so she told nurse to no to the ?oor. . immediateiy went to the ?oor and then, a few minutes ister, she contacted . ., . for a blood pressure cuff. sported that she ran to the room. When she arrived was petitioning CPR. thenssked someone to get an oxygen tank. and ran to get the tank. When they returned. their Put the mask on David and start continued CPR. stated that she could not remember who was or who was in the room at the time. stated that she did not know what time 911 was sailed but that made the coil. She stated that they worked on David for more tharr an hour. but they could not revive'hirn. Two odditiosei nurses who were not presenton-the night of the incident were stso interviewed. One of the nurses reported that-David had rte-serious mortise! Issues. She stated themevid?s behairior had resentiy' improved and she stirihoted "the" to new medication. The other horse reported that nurses srsrequired-to resort to the scours. She sis'o noted that Wordsworth erovides? 'the'nurse with oeiitiier teiephones. Several other Wordsworth staff members 'wsreinterviewed as collateral messes. was siso rem interviewed a resid?htiai oounseior. reported that he was not aware of any issues that David had with staff or with other residents. He noted that during a meeting that evening. David ted the room without permission and .iwertt ott?itor several minutes. . . con?rmed -- - statements and added that was upset because he thought it was disrespeotiui of David to team the meeting without permission. eiso stated that. do ring the conversation between and the resident who owned the iPod, Joirted the conversation but it was not clear to him why became invoived. also stated that he did not know why went into Bavid?s room because was not assigned to Geyid?s shit that nioht. stated that he did not see the restraint but reported that he saw staff?s hands on David. Neither . .. . knew if staff had 'errottgh speed to do 3 preset restraint since there were many things on the ?oor. the team leader. reported that he had worked at Wordsworth for toss than one month. He stated that he did not test as it he had been properly trsihsd on his stated that he gave no instructions that evening 'beeasits he did hot Know what to do. He stated. however. that staff shouid have noti?ed trim when they needed to force their way into David?s room. The investigators contested the Director of Nursing to obtain information regarding activities in the nursing department, soot: es shiit logs. it was reported that the mummy dope-tiniest does not keep record of activity that occurs on to shift. A review of telephone records would be the oniy way to determine when the nurses received colts. The Psi-3H8 investigators received a report from the Philadeiphia Fire Department. When in route to Wordsworth, the dispatcher intimated emergency medioai services that it was a "code blue? coil. After they arrived at Wordsworth, the responders were dsiayed in getting to Davidheoeose Wordsworth security did not know the fioor where the r: inergency was occurring. Ssvid?s room was disheveied. Someone reported that David had destroyed his room otter being confronted about the stolen iPod. Staff stated that they tried to restrain David ?out that he hit his head on the ?oor; took a deep breath, and then coded. Po-iioe were then dispatched to the scene. 'i?hs interviewed severai other Wordsworth staff members but they did not have ?rst~hssd knowiedge of the incident. They ooutd only provide information that they had been given by other staff and residents. The PA-DHS investigators attempted to residentisi counselor, out he retained an attorney and rehased to be ioterviswed. were not interviewed prior to the Act 33 meeting. assigned from Wordsworth on stretcher 25}, 20%; resigned on October 21, 20-18. Both triers empioysd as rssidentisi oounseiors at the time of the incident DEPARTMENT OF HUMAN SERVICES ACT 33 TEAM FATALITY REVIEW REPORT: DAWB HESS The repart determination is pending the canctusian cf the criminal Investigation. The police investigation is ongorng. famity had :19 prior history with Phttadetphia DHS. David?s famiiy was known to Lebanon Cuunty Children and Ycuth Services. 1. camplimw with - an - The ?ats-a fS-r residential staff. The Team natSd that Wardswarth matted tr: better devatsp itS staff th'rcugh wathirzg aria a wmprahensive stat? devaiepment ?agrant. TSE Team questiarted if training that staff received. such as crists interventicn am! the use at physicai rEStraintS, was su?iciartt. . Wordsworth teadership nate? that refresher trainings. sum as haw to deescaiatS sttuaticns and haw to dc physicat restraints. are prmrided annuaiiy. There is no regular practicS? hawaver, in namamergent Situatians nar do the Siways practice thEther, - - The Act 33 TESS: feit that trainings Hearted ta Samar mare regulariy and Inctude whSre staff cauid practtaa ta situatians. During emergency Situatians, staff must respond quickly and They need ta grammatical}? kriSw what ta drain a situatiarr. The Act 33 Team questia?ad if tha Staged Sf headteck during Eavid?s restraint was an .aaematy or it th-SSI?actice WSS a carrim?m during Sitter restraints. The Team what and Sragedureis maid be put into ptace ta ensure that nu other staff members w?utd err-gage in tmpreper reStraint it was restarted that 2113 restraint twining inctudSS the directive that nothing shat-rid be put on a ynuth*s neck during a restraint. The Act 33 Team stressed that training shSSid atSS ctearty prahtbit punching a resident white empicying a restraint. :3 Tha Act 33 Team that the use of restraint: needs to be practiced regutariy and must be supervtsed by high ESvet staff Witt: Srevtde redirection SS necessary. :2 Tha A?t 33. Team aiSS noted that, when an empiayee ES disctSiiSed for victatirsg a premature at praiwai, they must receive timber training in that area before tirSy are returned to their pasitirm. For instance; an emptoySS for imprapar at restraint shank! receive remediai training in restraint SSE befare returning ta empiaymant . The Act 33 Team noted that, white staff was attempting ta deescatate the situation. Siameone sheuid have concurrentty catied nurse. The Act 33 Team recegnized that CPR was Sat Sane S?rrectiy by any Sf staff: several staff membars reperted giving CPR, through it was teamed SEPARTMENT OF HUMAN SERVICES ACT 33 TEAM REVIEW REPORT. . DAVID HESS that staff had performed oniy chest and that no one gave David rescee breaths. a Werdeworth leadership reperted that that American Red Crass provides CPR twining te its staff. a The Act 33 Team noted that there is a ?mentai barrier? that needs in be overcome in order in provide mnuth?tetmouth rescue breaths. Though Wordsworth was not required to have breathing masks. the team neted that this relatively inexpensive piece of equipment may have helped to overcame compunctions that the staff may have had. . The Act 33 Team did not understand why dean not require that nurses keep shift legs to denument their activities. This informatien ceuld have been important in understanding why staff had dit?euity dentadting the nurses when David became unresponsive, . a Wordswerth leadership reported that radiations are put into individuat tiles and that theddctiment 'i's-previded at the end at the shirt. There is not a summary document with the ndtatiehsi its-rail at the residents, hdwev'er. . the Act '33 "Teeth feit it was Unacceptabie that emergency medicat responders were delayed in getting to Bavid. in additidn to Werdsworth staff's failure to cell 911 in a timely manner, when the ?rst reepnndere arrived at Werdswerth, security personnei did not knew en which finer the emergency was occurring. This further detayed emergency medicai care for David. a Wordswerth leadership noted that, when 911 is dated. poiicy dictates that the notifies security of the emergency. The Act 33 Team feit that it was net steer if Wordsworth was able to meet David's hehaviorai health needs. Werdswurth inedership ranted that they had agreed to accept David into their pregrem in spite of the fact that he had been denied by numerous other They eisp reperted that Wardemith e?en accepts such clients into their facility. a Werdswerth leadership meted that, in the past, yeuths with a need fer such a high ievet of care were after: sent in in other states. Other states are permitted in use different types at treatment and different restraint methods, When this practice stepped. many at these chiidreh ended up being pieced at Wordsworth. The Act 33 Teeth noted that. it Wordswerih could net meet David?s needs, he sheuid not have been admitted intn the program. Children must be admitted in the therapeutic environment that wiil best meet their individuei needs. The Act 33 Team stressed that keeping dhiidren einserte their homes can be and aheuld not optima-int: the need for hehavierai health treatment. Wordsworth noted that their current Residentlai Treatment Program accepts yoethe with mental health issues some at when: also have delinquent issues. Since yauthe in these two very different groups eften need different types of treatments, additidnai services are necessary. Wordsworth leadership reported that they had pretiminary conversations with to discuss creating two programs to separate the populatiens. . The Act 33 Team felt it was inappropriate that the decisiens to centront and then restrain David were made by an empteyee who had lithe training and experience. Proper protocols we e- cteerly net teiiewed. The decisions shonid have been made by eupenrisery staff that had eddittenel experience and training. DEPARTMENT OF HUMAN SERVICES ACT 33 TEAM FATALITY REVIEW REPORT. . HESS Wordsworth CEO Debra Lacks reported that the funding for the youths that they sen/ice needs to be increased in order to attract more experienced applicants who are better able to meet the needs of the youths. Wordsworth line staff earns approximately $13.00 per hour. She also stated that the prospective staff is otter: young and comesfrom the same troubled neighborhoods as the youths Wordsworth serves. DHS Commissioner Figueroa noted that line staff spend the most time with the youths and they often have the highest turnover rates in Residential Treatment Facilities. in these types of situations, supervision and support are criticai. . The Act 33 Team questioned if there was a cuitural norm at Wordsworth which discouraged the reporting of incidents. The Team was worried that an institutionai culture such as this could prevent staff and youths from providing information that impacts the well?being and safety of Wordsworth residents. The Team aiso questioned if residents feit safe reporting their issues with staff. a The Team discussed the sileged prior incidents of staff hitting David. There appeared to be an antagonistic relationship beh?eso David and 7 Wordsworth iesdership denied that any of these incidents had been previously reported to them. One of the aiiaged incidents reportedly occurred in the cafeteria. There are no cameras in the cafeteria or in the residents? rooms. There are video cameras in the common areas and in the school. a Wordsworth ioadership noted that there are ongoing conversations with star? regarding accountability. Staff is encouraged to report incidents and is permitted to submit concerns anonymousiy. Wordsworth leadership stated that, if the prior incidents had been reported, their protocol dictated a review of any available video footage. a review of David's ciinical history and any factors which may have contributed to the situation. removing staff from David?s unit, and retraining the staff in proper procedures. . Wordsworth leadership stated that there is a Chiid Advocacy Group at the facility and also a grievance poiicy. They noted that residents often con?de in their therapists who are then mandated to report the incidents. 2. Services to David and the extended family: a At the time of the report, David was placed at Wordsworth via Lebanon County. There are no other minor chiidren in his famiiy. DEPARTMENT OF HUMAN SERVICES ACT 33 TEAM FATALITY REVIEW REPORT: . DAVID HESS RECGMMENDATIONS FCR CHANGES AT THE STATE AND LOCAL LEVELS: 1. Reducing the likellhaod of future chil? fatalities and near directly related to child sham and neglect. The Pennsyivania Depanment of Human Sewices should consider amending its regulations regarding ?rst aid suppiies far residen?ai treatment programs and other congregate care facilities. Curran? regulations do not require to have access ta ?fe-saving equipment such as CPR banter masks and auicmated externa! de?bri?ators (AEDs). Staff sheuid aisg receive reguiar training on how to properiy use the equipment. a The Ph?adeiphia Bepartment of Human Services should cansider amending its contractual requirements far cmgregata care pmviders to mandata that facilities have access to fife- saving equipment such as CPR barrier masks and Eliminated externat defibriilatars Staff sheui? ai?o raceive regular training an new t3 prope?y use iha equipment 2. Mei-snoring airs-id inspecticn of'ca?nty agenciw. . There were no recommencfatiens. DEPARTMENT OF HUMAN SERVICES ACT 33 TEAM FATALITY REVIEW REPORT .- HESS. ACT 33 TEAM: 9%:sz {mice of Ghiidren, Yauth and - Southeast Regional Office: PA-tii-is Office at Mental Heaitii Arid Substame Abuse Services: ti??erdswarth 8tafi: Lebanon Gaunty Prebatian: Dr. Sam Galina, Chief Medical Examiner, City of Philadeiphia Figueroa, Commissianer, DHS Jessica Shapiro. First Deputy Commissianer. Di-ls Kimberly All, Deputy Commissioner cf Child Welfare, DHS Gary Williams, Chief Learning Officer, DHS Laurie Dow, Divisicnal Deputy City Solicitor, City of Phiiadelphia Law Department Jennifer Bond, Act 33 Program Manager, 0H8 James Carpenter, District Attorney?s Office. City of Phiiadelphla Dr. Jeanne Wand, Physician. Br. Marla MaColgan, Directar, St. Christopher?s Hospital Chiid Protection Fragrant 091'. Shirley Mama, i?hiiadeiphia Police Department. Special! Victims Unit Jam-tine Lisitski, Executive Director, Wanton Against Abuse Fianna! 3612111333, Deputy Chief, attics of Student Rights and R??p?asibi??es, Sena-oi District D-lmctar, mammal, Ohiid and Famiiy Health, Bapartment a: aim-ii: .Hsaith . Gina Weai. 9H8 Num?a B?r'i Harris, Raheamah Shamsid?eari Hampton. Director mark-Davis. Fragrant Representative Sherri irvis?Hiil, Frags-am Rapmse?tativa Pat Waifi, Fragrant Representative 3113in Neptune, Program Representative Karen Program Representative Lynda Maura, Program Representative Emilio Pachesa. Program Repmsentattve W. Jerome Buttcin, Program Representative Debra Lacks, President amt Chief Executive Gfiicer Jennifer Hermann, {)5qu Executive Director Samara Speakas, Program Direciar Alyssa Tasi. Ccmpiiance Officer Dr. Mark Nuvitsky, Wiillam L. Earztom Niamey Adam Yano?, Germ-at Counsai Saiiy Barry; ?irector Susan Christner, Deputy Director DEPARTMENT OF HUMAN SERVICES ACT 33 TEAM FATALITY REWEW REPORT DAVID HESS Approv by the Act 33 Team: . DATE: 1/ 3 1/201? Dr. Sam Guano, Chief Medical Examiner Chair of the Act 33 Review Team Raviewed and Approve?: A ia Figsaroa Commissioner cf 9H3 Femardad 1:3 The Honorable James F. Kenney Mayor a? the City at Philadaiphia charded to Raheemah Shamsid-?Deen Hampton DATE: 02 [l 22 2 Department at Human