The state of Georgia continues to have people with developmental disabilities die while under state care, with 160 deaths in the past fiscal year, according to a court-appointed observer.

The state often overlooks potential neglect or mistreatment uncovered by its own investigators, such as a woman who drowned in a bathtub this year, independent reviewer Elizabeth Jones said.

The U.S. Department of Justice sued Georgia over the conditions in its state hospitals, and the Georgia Department of Behavioral Health and Developmental Disabilities agreed to a settlement in 2010 that requires moving individuals with disabilities from state institutions to the most appropriate integrated setting, and to provide greater services and support for those in community settings. Jones is monitoring the state’s compliance with those provisions and reporting to the U.S. District Court in Atlanta on the state’s progress.

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Site visits to current providers also found some are employing poorly trained and supervised staff. One resident, referred to only by the initials B.B., ended up hospitalized and recovering in a nursing home after she refused to eat and lost weight due to poor care in the home.

“The apparent indifference shown by the residential staff was equally disturbing,” Jones noted. With another resident referred to as J.B., the nurse consultant found the man apparently heavily drugged, noting he “was slouched down in the chair with his head hanging down” and had a black eye the staff could not explain.

An Augusta Chronicle investigation in 2015 found nearly 1,000 deaths in two years among individuals with disabilities in the community under the state’s care, and the state later agreed to a more robust system for investigating and reporting deaths. In fiscal year 2017, there were 160 deaths and 68 investigations, but “the findings and recommendations in certain investigations raise concerns about thoroughness, and, even more importantly, the legitimacy of the conclusions drawn from the investigation,” Jones wrote.

One glaring example is an individual known as C.Bi who drowned in her bathtub Feb. 17 despite a care plan that required caregivers to keep her in “line of sight at all times,” the report said. Yet there was no finding of neglect, Jones noted, despite reports that the staff had left her at other times to go to McDonald’s and “conflicting statements” from the staff about what they were doing that day.

“Multiple elements of this death are consistent with a finding of neglect,” Jones wrote. “It is disturbing that that conclusion was not reached.”

Some investigations are not completed yet, including one from January where “there was a concern about neglect” and another from June in a home where three residents have died since 2014. Jones wrote she “has identified five agencies that require additional, more intensive review due to the number or circumstances of unexpected deaths.”

The department would not answer detailed questions about her report, but said Jones “continues to provide reflections and recommendations that are valuable to DBHDD,” Press Secretary Angelyn Dionysatos said in a statement. “As we progress toward the end of the extension agreement, DBHDD is focused on sustaining the significant system gains that have been achieved and addressing remaining areas of required compliance.”

Because the state failed to meet its original deadline, the settlement agreement has been extended and the latest deadline is June 2018. As of June 30, there were 167 people with developmental disabilities still in the Gracewood wing of East Central Hospital in Augusta and 366 to be moved overall, according to Jones.

With the state moving 26 people in fiscal year 2016 and 29 in fiscal year 2017, moving everybody to community settings “would take the state a dozen years or so,” she noted. A “substantial barrier” to those community placements is a lack of appropriate providers, but the state has failed to recruit a “single new provider” to provide care in those community settings since agreeing to a recruitment plan, Jones said.

Staff writer Sandy Hodson contributed to this report.

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