GRAND RAPIDS, Mich. (WOOD) — State regulators cited one of Michigan’s largest child welfare agencies for failing to supervise a teenager who took his own life at the facility in July 2016.
According to the 45-page Special Investigation Report released to Target 8 investigators Friday, state inspectors found that no one on staff noticed when the teenager did not show up for an on-campus work program at 9 a.m. on July 13, 2016.
Forty minutes later, a staff member came across the 16-year-old’s body hanging from a tree on the campus of D.A. Blodgett – St. John’s Home located at 2355 Knapp Street in Grand Rapids.
“We are devastated by this incident and are working diligently to implement changes aimed at preventing any such tragedy from happening again,” read part of a statement released by the residential treatment program Friday.
The resident, a 16-year-old from the Mount Pleasant area, had been living at St. John’s Home since September 2015. But it wasn’t until March 2016 that D.A. Blodgett – St. John’s Home learned the teen had tried to hang himself at least twice before moving to the facility. His mom then found a noose he had tied in his closet at home.
“Resident A has also expressed to his therapist that he is having nightmares of dying by hanging himself and does currently have some thoughts of not wanting to live,” a staff member wrote on a form on March 15, 2016.
That’s when the teen was placed on “100 percent supervision” status, which meant the resident “must be with in eye sight of staff” at all times and, if in his bedroom, must be checked on every three to five minutes.
Yet the staff allowed the resident to walk alone on a daily basis to the on-campus work program in which he participated.
“The staff at Hunting House allowed Resident A to walk out of the house without staff with him, and without watching him get to where he needed to be during the time he had his job, beginning in the spring of 2016,” wrote licensing consultant Kathy Fiorletta in her report.
“Resident A was placed on the 100 percent supervision status because he was assessed by his therapist to be a risk to himself due to past suicide attempts,” Fiorletta continued. “That risk was not taken seriously by staff, as they reported he was not a behavioral problem, he was trustworthy, a hard worker, etc.”
According to the report, the teen’s treatment team knew he was in a “fragile” state but did not see any immediate concerns.
The report indicated that, if staff did have concerns, they would have increased his status from 100 percent supervisory to “at risk” or “suicide watch.”
“The 100 percent supervision for Resident A was not like the 100 percent supervision they normally provide, Fiorletta quoted one staff member as stating. ‘It was relaxed,’ meaning Resident A was trusted.”
The 100 percent supervisory status was also supposed to restrict the teen from having items in his room that could cause injury, including sharps, long sleeved shirts, pants, belts or any cords or strings.
“Resident A was able to keep items without staff knowing and ultimately used one of the items to successfully hang himself,” wrote Fiorletta in her report.
In total, the state cited D.A. Blodgett – St. John’s Home for violating six rules governing child caring institutions in Michigan. The violations included failing to supervise the teen, failing to notice when he was missing and failing to monitor his access to dangerous materials.
Additionally, the report made it clear that the state found multiple employees – including staff, managers and a therapist – responsible for the failings.
“None of (the staff) were able to answer when or why (the resident) was allowed to be out of sight of staff, despite each of them knowing that (the resident) was to be on 100% staff supervision and what that meant,” wrote licensing consultant Fiorletta in the report.
“As a result, it has been assessed that all of the staff employed at Hunting House… lack ability to perform their assigned jobs. This includes the house manager, who also did not ensure the safety of Resident A and did not hold staff accountable for not performing their required job functions. The therapist… is also lacking ability as she did not ensure the terms of this (100% supervision) status were being followed.”
The report also noted that the therapist changed her story about whether staff contacted her every 24 hours as required.
“(The therapist) also indicated that the staff were making contact with her every 24 hours as indicated on his status sheet to discuss the need for continued status, however, in a later subsequent interview… (the therapist) recanted her statement and indicated staff were not making contact with her as indicated on the status sheets,” wrote Fiorletta.
Furthermore, Fiorletta wrote that an employee later “admitted to falsifying the status sheets indicating they had made a phone call to (the therapist) at 8:30 p.m. to confirm the need for continued status.”
The licensing consultant also reported that the therapist allowed a Masters of Social Work intern to conduct the teen’s therapy sessions.
“(The therapist) advised that her intern.. was in charge of individual sessions, but she did oversee them, and both of them facilitated the family sessions,” explained Fiorletta in her report.
In that case, the licensing consultant with Michigan’s Division of Child Welfare Licensing cited D.A. Blodgett St. John’s Home for a “Contract Violation.”
“MSW Intern was doing individual therapy sessions that required a licensed therapist and writing service plans,” read the report.
The facility, which treats teens with cognitive emotional and developmental impairments, diagnosed the young man with persistent depressive disorder, dysthymia, disruptive impulse control and conduct disorder.
In the teen’s obituary, his family wrote that he’d been adopted from Ukraine at 18-months-old, and that he had recently finished the ninth grade while residing at D.A. Blodgett- St. John’s Home in Grand Rapids. They went on to say that despite a hearing impairment, he had a “remarkable ear for music and could play pieces by memory on the trumpet, piano or guitar after hearing them.”
The family told Target 8 that it could not comment on the teen’s death because of a “lawsuit.”
For now, the state has changed the organization’s license to “provisional” and will review it fully in six months.
Here’s the entire statement from D.A. Blodgett – St. John’s Home:
“D.A. BLODGETT-ST. JOHN’S OFFICIAL STATEMENT ON STATE OF MICHIGAN REPORT
In July, there was a suicide attempt involving an adolescent in our residential treatment program in Grand Rapids. The teen passed away a few days later at an area hospital. We are heartbroken by this loss and continue to hold the family and loved ones in prayer.
After the incident, we voluntarily reported what happened to state agencies and immediately began an internal investigation, reviewing protocols, policies and procedures.
The state recently concluded its investigation and issued a report of findings. With the state’s report, along with our internal investigation, we are taking immediate action to change and improve our policies and procedures and will comply with the state’s request for a corrective action plan within the next two weeks.
We are devastated by this incident and are working diligently to implement changes aimed at preventing any such tragedy from happening again.
Due to the sensitive nature of this matter, and out of respect for the adolescent’s family, we will not be commenting beyond this statement.
We continue to be committed to our mission of helping children, youth and families heal from trauma and find hope.”