The Massachusetts Department of Early Education and Care, the state agency that licenses residential schools serving children 0-18 and C766-eligible individuals 18-22, released an investigative report today, outlining a number of appalling findings, related to a 8/26/07 “prank” involving 3 JRC clients.

Some findings contained in the report:

• The JRC clinician assigned to the Stoughton house where the incidents occurred, reported the students are high functioning.

• Residential staff were physically abusive towards two residents.

• Residential staff failed to protect the health and safety of residents.

• Residential staff failed to follow JRC policy and training regarding medical treatment which resulted in a delay of medical attention.

• A former resident, who had run away from JRC, phoned staff, posing as one of JRC’s quality control monitors, and gave a series of instructions to staff to awaken 3 residents and administer shocks for behaviors exhibited earlier in the evening.  A series of these calls were made between 2:00 a.m. and 4:45 a.m. during which time the former resident continued to order staff to administer shocks and restraints.

• Although the licensee (JRC) claims the victims were evaluated by JRC nursing staff, JRC’s physician, as well as the victim’s treating clinical Doctor, and found to be in good health, one victim was further examined at a hospital (name redacted) and was reported to have two areas of first degree burn[s] related to the presence of the GED.

• Based on the actions and expressed opinions of the [JRC] staff, it can be ascertained that the JRC program policies were set up in such a way that it took decision making away from the staff.  The staff were unclear on who was the responsible person(s) for the administration supervision of the program and failed to exercise any independent judgment in the matter.

• Video surveillance revealed that one resident was restrained on a 4-point board despite the fact the individual was not approved for this particular “movement limitation” treatment.

• The residential staff involved in the incident acknowledged they were unfamiliar with the use of aversive treatment, delayed consequences or reporting abuse and/or neglect.

• One staff stated he assumed that it was a test from the Quality Control to find out if he was following procedure.

• When interviewed, direct care staff misinformed investigators as to their activities.  For example, staff claimed they were sleeping, doing chores, and unaware of the incident.  Video surveillance revealed staff were aware and communicating with one another about the activities referenced in the report.

• After receiving shocks, the staff did not respond to resident’s complaint of pain or notify the JRC Nursing Director who is available 24 hours a day for emergency calls.  One resident was said to have informed staff on several occasion that his leg was “killing him” and could be heard asking staff to call the nurse.  It was reported that staff was made aware of the resident’s complaint and “blew it off.”

• At 4:32 a.m., one resident told staff that he was sweaty, his mouth was dry, blood pressure was racing and he felt as though he was about to have a stroke.  The resident had asked and was given water but was otherwise not evaluated by any staff.