Report: Glenwood’s disabled residents at risk due to poor leadership, lax oversight

A long-awaited review of a state-run home for the disabled says millions of dollars are spent each year on overtime in the facility but the home still can’t ensure the safety of the 190 Iowans who live there.

The state-commissioned review of the Glenwood Resource Center, which serves some of Iowa’s most vulnerable, intellectually disabled residents, has found violations of residents’ rights; a high number of abuse and neglect complaints; excessive use of physical restraints; a “toxic” work environment driven by fear; ineffective leadership; poor oversight by the Iowa Department of Human Services; and an insufficient number of physicians to care for residents of the home.

The review also found that sometime after 2010, the home quietly dropped many of the reforms it had implemented to appease federal investigators who had determined that residents’ rights at Glenwood were being violated.

That particular finding is notable because Glenwood is currently the focus of another federal investigation into the alleged violation of residents’ rights. The current probe centers on complaints that the facility’s former superintendent, Jerry Rea, had initiated plans to use residents of the home in experiments related to sexual arousal.

In addition to investigating those complaints, the U.S. Department of Justice is also looking at whether the home has provided inadequate medical and nursing care to residents, engaged in needless and harmful restraint practices, or caused needless physical injury to residents.

Shortly after the DOJ launched its investigation late last year, DHS, which runs the home, fired Rea and commissioned its own set of investigations, one of which was recently completed and resulted in a report authored by Mark S. Diorio, a consultant and mental health expert from Virginia.

In his report, Diorio says he made no attempt to examine the sexual-arousal studies that triggered the federal investigation, saying those and other issues had been “assigned” by DHS to other experts and to law enforcement.

But Diorio does say the “research efforts” initiated by Rea had become a “major focus” of Glenwood under Rea’s leadership and that those efforts interfered with the home’s primary mission of caring for its residents.

DHS officials say that of the 117 recommendations that accompany Diorio’s report, the department is currently in the process of implementing 90 of them and has put others “on hold” due to the COVID-19 pandemic.

Among the problems cited in Diorio’s report:

• Undoing DOJ reforms: In 2004, the state entered into a formal settlement agreement with the Department of Justice, agreeing to make major improvements at Glenwood due to allegations of residents’ rights being violated. In 2010, after six years of effort, Glenwood was deemed to be in substantial compliance with the terms of that agreement, but sometime after that, “senior leadership” at the home made the decision to undo some of the reforms that had been implemented. The report says “it is not clear when this breakdown occurred, or who authorized it at DHS.”
• Lack of leadership: Glenwood has lacked effective and consistent leadership, a problem compounded by a lack of oversight and monitoring by DHS. Between 2008 and 2019, a period of 11 years, the home had 10 superintendents, some of whom only served on an interim basis. “Any organization that has this kind of turnover in leadership will typically experience short-  and long-term problems,” the report says.
• A culture of fear: Top administrators at the home who served on its executive committee disagreed with some of the actions taken by Rea, but didn’t speak up due to fear of retaliation. Executive committee members described Rea as controlling and intimidating, and said he created a hostile work environment in which retaliation and fear were common. The culture at the home was “consistently described as authoritarian, disrespectful, non-supportive, toxic, frustrating, retaliatory and unfair” by the staff.
• Death investigations: While Diorio didn’t look at medical issues within the home, he did review information from the home’s Mortality Review Committee which examines resident deaths, and concluded the issue requires “immediate attention.” He said that in reviewing 20 different death reviews, he found no recommendations for corrective actions. Ten of those cases were also reviewed by The Columbus Organization, which is contracted to assist with mortality reviews, and in seven of those cases a physician working for Columbus provided detailed recommendations for action.
• Problems left unaddressed: While the home collects a significant amount of data on issues that pose a threat to residents, there’s little indication of corrective action being taken. For example, in a monthly report from July 2018, the home noted 37 residents had fallen and 29 had experienced an increase in falls from the previous month — but there was no evidence of any action taken to address the issue. Also, there was a 63% increase in the number of medication errors that month, but again there was no evidence of corrective action taken.
• Poor quality-of-care oversight: The home’s quality management director said “she has had minimal training on quality management methods and on the analysis of quality-indicator data.”
• Abuse investigations: While the home has four full-time abuse-investigator positions, one of the four positions is left vacant most of the time, and the home is not complying with its own policy on staff certification of its investigators. From January 2019 to November 2019, there were 907 so-called “Type 1 investigations” at Glenwood, an average 82 per month, and the majority of those involved allegations of abuse, neglect, mistreatment or exploitation. “A significant number of the allegations were for physical abuse or sexual abuse,” the report states. “Very few allegations were substantiated after the investigations were completed.” The report says the number of allegations “is significantly more” than what’s typically reported at similar facilities, while the percentage of substantiated allegations is lower than expected. “I have serious concerns about the integrity of the abuse/neglect investigative process,” Diorio reported.
• Excessive use of restraints: The report cites an excessive use of physical restraints, noting their increased potential for serious injury to both staff and residents. The report indicates “a system-wide failure and a serious breach of clinical responsibility” at multiple levels. “Clearly, Glenwood Resource Center violated the right of individuals to be free from unnecessary restraint,” the report states. In 2019, Diorio found, the number of staff injuries associated with the use of physical restraint rose to 51 from nine the previous year, a 466% increase.
• Psychological services: The home’s residential workers expressed concern about not knowing who the psychologist was for various residents. Some workers told DOJ investigators they had not seen a psychologist for at least one year. “This is a serious problem and brings into question whether the psychology staff actually know the people they support,” the report concluded, adding that “the psychology staff do not have sufficient knowledge of dual diagnosis,” are “unfamiliar with standardized tools used to assess mental health disorders,” and too often base their treatment decisions on anecdotal information.
• Staff shortages: Glenwood needs 416 residential treatment workers to provide minimal coverage for residents’ needs, Diorio found. However, the home has only 308 such positions, leaving the home short 108 residential treatment workers. “This is a major problem and will result in significant mandatory overtime ($3.3 million in FY 2019, and predicted to be $3.8 million in FY 2020), staff burnout, and the lack of adequate and effective supports,” the report says. “Due to direct-care staffing shortages and high staff turnover rates, Glenwood Resource Center cannot adequately identify risks and ensure residents’ safety.”
• Behavioral support plans: The individualized written care plans for residents were seriously lacking, sometimes omitting critical information and in other cases using language that was so vague as to be useless. For example, one resident was described as showing signs of “socially inappropriate behavior,” and the corrective action for that was to engage in “appropriate social behavior.”
• Medication for behavior control: Residents of the home are given psychotropic medications at an abnormally high rate — which can be an indicator the staff is using drugs simply to control residents’ behavior. Of the 194 residents at Glenwood in April, 141 were prescribed psychotropic medications — an “an unusually high” rate, and twice what might normally be expected, the report said, adding that additional review would be needed to determine whether the medications were clinically justified.