MAPping abuse 

In October 2004, a teenage autistic boy known as “Paul” was repeatedly attacked by a fellow resident during a 10-day stay at Montana Developmental Center (MDC), a state-run residential mental health facility in Boulder. According to a report released last month, Paul left the facility bruised and bitten on multiple parts of his body.

The Montana Advocacy Program (MAP)—a federally funded nonprofit watchdog organization—released investigative findings last week detailing gaps in MDC’s policies MAP says led to Paul’s neglect and subsequent abuse, and highlighting alleged deficiencies in state law that prevented earlier identification of the abuse.

According to the report, entitled “Failures of Oversight at MDC,” Paul was bitten and scratched by an aggressive resident on two separate occasions, but MDC never fully investigated the incident and didn’t take responsibility for exposing Paul to his attacker.

MAP initiated its own investigation at the behest of Paul’s mother, who MAP says uncovered evidence of abuse and neglect. MAP presented its initial findings to three state oversight agencies in early 2005, but the Quality Assurance Division of the Montana Department of Public Health and Human Services (QAD) was the only agency to act on the report, issuing a finding on March 14, 2005, that MDC residents were in “immediate jeopardy due to MDC’s failure to comply with certain federal regulations designed to keep them safe from abuse and neglect.”

MDC had earlier notified the state Mental Disability Board of Visitors (BOV) of the abuse against Paul on Oct. 27, within weeks of its occurrence. But after reviewing MDC’s report, the BOV initially endorsed MDC’s assertion that its staff did not neglect Paul when they left him alone in a room with the resident who had attacked him four days earlier. The BOV eventually reversed its findings only after receiving MAP’s report months later.

A similar MAP investigation released last September led to a state-imposed two-month admissions ban at Kids Behavioral Health, an 85-bed state-licensed treatment facility for troubled youth near Butte. MAP recommendations for MDC aren’t as harsh. MAP’s primary recommendations include requiring MDC to assign an independent child protection specialist to investigate incidents of abuse, and suggests amendments to state laws that would broaden the authority of state’s oversight agencies.

MDC’s attorney hadn’t seen the MAP report and couldn’t comment on the recommendations as of press time.

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