An Open Letter to Consumers, Families, Advocates and Staff

Rudy Wallace, who had been a resident of the St. Louis Developmental Disabilities Treatment Center for thirty years, died from scalding burns received at the habilitation center’s Northwest Campus. My heart goes out to his family and friends. No resident or family should have to endure this sort of tragedy. The entire Department and Mental Health Commission join me in extending our condolences to Rudy’s family.

The public needs and deserves to know precisely what happened. We are cooperating fully with the St. Louis County police who have taken over the investigation of this case and have requested that the Department suspend its internal investigation until the criminal investigation is complete.

Conflicting information has been reported about just how this tragedy was able to occur. From our preliminary investigation, we know that the water temperature in the hot water supply had risen to dangerously high levels. It is unclear whether problems with a water mixing valve in the group home where Mr. Wallace was residing directly contributed to this tragedy or whether an unauthorized manipulation of the apparatus for controlling temperature contributed to the injury. It is also unclear whether the scalding was the result of immersion in a tub or from spraying of extremely hot water during a rinsing off after Mr. Wallace had been placed in the tub and washed. Water is safe for bathing at 100 degrees Fahrenheit. When the water temperature in the home was tested about three hours after the incident it registered at 130 degrees Fahrenheit. Exposure to water at that temperature would result in 3rd degree burns in about 30 seconds. If the water temperature was just three degrees higher, it would only take 15 seconds to create 3rd degree burns.

All of our facilities are required to routinely check water temperatures in all living areas to assure safe water temperatures. In addition, it is a matter of policy that staff check the temperature of water prior to bathing consumers, and they are routinely trained with respect to this practice. As a further safeguard at the Northwest Campus, we are installing locks on each cold and hot water supply valve to prevent tampering with controls by unauthorized individuals, and assuring that similar controls are in place across all facilities.

Our policies require calling ‘911’ immediately in the case of a life threatening event. Our preliminary investigation indicated that 911 was not called and that instead a private ambulance service was called more than an hour after the incident occurred.

Our policies also require that police are notified when we suspect physical injury may be due to abuse. Our preliminary investigation indicated that the police were notified by the hospital, and not by facility staff.

Our preliminary investigation indicated that staff had been appropriately trained in these policies. If, however, further investigation reveals that the failure to implement these policies resulted from a lack of adequate education, we will immediately implement additional training measures.

The information we gathered in our initial investigation led to the termination of two staff. More actions may follow based on the results of the criminal investigation.

As Director of the Department, I want to reiterate in the strongest possible terms that the Department will not tolerate abuse or neglect of the vulnerable people we are entrusted with serving. Assuring that consumers are safe and receive high quality services and supports requires vigilance and a commitment to continuous improvement.

In recent months, we have taken several steps to strengthen the quality of care and oversight of our state facilities:

• In the past, abuse and neglect investigations were generally conducted by staff at each facility. Last fall, in order to assure consistency, independence, and a high standard of quality, all investigations were placed under the authority of the DMH central office investigation unit, and more rigorous investigation procedures and timeframes were initiated. Although resources were redirected from the facilities in order to support the centralized investigation unit, we have requested some additional resources in order to assure that we can appropriately meet the demands of providing timely and accurate investigations of high quality.
  
  
• Last fall, we also began implementing facility scorecards that allow us to track key performance indicators of the quality of care in facilities. The scorecards help us identify areas for improvement, as well as patterns and trends that require further examination.
  
  
• In January, we moved the day-to-day supervision of all state mental retardation and psychiatric facilities under a Facilities Operation Team that reports directly to me. The primary purpose of this change is to bring a stronger focus to assuring the quality and consistency of care across facilities. The MR/DD and CPS divisions remain responsible for all policy and program development for their respective systems of care, including any changes in the role or function of the facilities within their systems of care. But the Facilities Operation Team is responsible for developing, implementing, and monitoring facility quality improvement initiatives.

Last Friday, I announced two additional changes that I believe will also contribute to assuring quality care:

• Based on my review of incident and injury reports, abuse and neglect investigations, audits, and performance indicators, I have concluded that it is important to significantly enhance the oversight capacity of the Division of Mental Retardation and Developmental Disabilities. Therefore, as an initial measure to enhance this capacity, I have appointed my Deputy Director, Linda Roebuck, as the interim director of the Division of Mental Retardation and Developmental Disabilities. Ms. Roebuck will do whatever it takes to ensure in every way that the Division can be relied upon to continue its mission in a manner that assures the very highest level of safety for the very vulnerable individuals it serves.
  
  
• In addition, I have asked the Columbus Organization, which has assisted us in assuring a high quality of care at the Bellefontaine Habilitation Center, to assist the Facilities Operation Team in providing supervision, technical assistance, and training for the St. Louis Developmental Disabilities Treatment Center to assure that the care provided is also of the highest quality.

I will not hesitate to take any other actions that I believe will help to guarantee consumers are safe, and receive the caring and competent services and supports they deserve.

Dorn Schuffman
Director