Who Watches the Watchman?

When allegations are reported and investigated – what happens if the investigators are actually part of the group the allegations are against?  Who provides an independent review of the allegations if the investigative agency can not be objective and actually do a real investigation?

These are questions I have regarding allegations of medical/nursing neglect and abuse  in the treatment of my son at the state operated intermediate care facility where he lived for 5 years.  The agency which does the investigation is the agency which runs the facility.  Unfortunately, even though the allegations are all medical and nursing care issues, the investigator did not have one healthcare provider review the allegations, documents or look into the fact that policies are outdated or do not meet the minimum standard of care.

But these “experts” have decided that the allegations are unfounded based on interviews with agency staff (non-healthcare) and administration.

We hear that the ICF/ID provides “comprehensive care” including healthcare and that there is oversight to ensure the care is being provided. Maybe in doing random surveys and looking at random samples, it may appear that the care is being provided.  Also in those surveys they do not look at the quality of healthcare or if the healthcare meets the community standard of care.  They seem to check that the providers have current licenses to practice their profession.  I think that we all know that having a license is not the same as providing quality care.

In my attempts to have an objective investigation I have contacted several other agencies in the state, including the Department of Health, and have gotten nowhere.  They all point to the Department of Social and Health Services as the agency providing oversight of the care.  Even though the ICF/ID is a medical facility by federal definition, our state defines it as a long term care facility yet the Long Term Care Ombudsman does not consider it a long term care facility and is of no help.

Clearly there are issues of neglect and abuse – any sane person could look at the records and documents and make that conclusion – for some reason though the Department of Social and Health Services and their investigative team has chosen to continue this neglect by failing to see the obvious and make corrections.

The issues fall into various categories of medical malpractice, medical neglect, restraints without consents, multiple injuries including fractures, false documentation of over 8 medications for over 2 years, failure to communicate with guardian regarding psychotropic medication changes, failure to provide prescribed medical treatments and transport to medical treatment center for prescribed treatments, applying splint to wrong foot, applying splint over shoe rather than inside shoe and failure to protect from client-to-client abuse are just a few of the allegations.  Maybe some of the issues actually fall into criminal categories.

Certainly in my mind the lack of ability of the investigators and the DSHS administration to do an objective and fact finding investigation is criminal.

Does one need to file a lawsuit to get anything done about this?



2 comments on “Who Watches the Watchman?

  1. The things you are citing are violations of the federal regulations and guidance concerning ICFs that are supposed to be enforced directly by surveyors from the federal Centers for Medicare and Medicaid or by a state agency that is their contractor for this purpose to assure that federal requirements (not just state regulations) are met.

    This is the link to the manual to be used by those surveyors which includes CMS’s refulations and Guidance: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_j_intermcare.pdf

    If your State does not care, go to CMS, go to your members of Congress. And demand compliance with these regulations and Guidance intended to provide these vulnerable people with the “active treatment” — at a level of quality that meets federal requirements. And consider contacting the Civil Rights Division of the U.S. Department of Justice — they have challenged inadequate conditions in ICFs in many states, as well as the Office of Civil Rights at the U.S. Department of Health and Human Services.


    • Thank you – Yes, I have reviewed this, the Code of Federal Regulations and the Social Security Act and they all are clear on what the standard is. I have referenced these to DSHS and I have also been told that the people who do the CMS survey are also the same people (employed by the state and contracted by CMS) who do the investigations.

      I have contacted a person in CMS who referred it on and then was told that it was the responsibility of DSHS to investigate.

      I will be meeting with my legislators soon with photos and documentation and I hope that they are able to at least have an objective investigation or an independent investigation done so that these issues can be corrected and others are not hurt.


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