Corvallis’ Children’s Farm Home… Post Suicide

dsc_3362The Oregon Department of Human Services has notified Trillium Family Services, the organization running Corvallis’ Children’s Farm Home, of their intent to revoke Trillium’s license to operate the child caring agency following the suicide of a resident there in August.

Currently, the revocation would affect only their Farm Home facility.

According to the Notice of Intent to Revoke, the Office of Adult Abuse Prevention and Investigations conducted an inquiry into the incident, “which resulted in a substantiated finding of neglect of a child in care by one of Trillium staff,” thus requiring the revocation of their license under Oregon law.

The Children’s Farm Home provides care for 85 minor residents in addition to outpatient clients, all ranging from children to adolescents with varying mental, emotional, and trauma histories.

Much of the work done at the Farm Home is conducted by Skills Trainers, or caregivers, some of them studying psychology and psychiatry, others with a more general background. Skills Trainers can become qualified to work at the facility by attending a week-long academy provided by the Farm Home.

The DHS notice indicates that of the two Skills Trainers on duty during the incident, one had already come to the attention of Farm Home management as possibly unable to perform, and the other was simply too inexperienced.

Night of the Suicide
According to the Notice of Intent to Revoke, the 15-year-old resident of the Farm Home attempted suicide on Aug. 15. Despite being resuscitated at a local hospital, he did not regain brain function and was removed from life support at the discretion of his parents on Aug. 16.

A Skills Trainer first observed the teen “engaging in self-harming behavior” in the resident’s room earlier that night. She noted that he had blood on his arms from “superficial wounds,” but refused to discuss his emotions. He told the Skills Trainer to go away, at which time she asked a medication staff to step in, to see how the teen would react to a male staffer.

At the time, the medication staff incorrectly concluded that the Skills Trainer notified either a supervisor or a qualified mental health professional as Trillium’s policy dictates when a resident expresses suicidal ideation or behavior. This could have placed the teen as a suicide risk, mandating visual observation.

Upon the Skills Trainer returning, the teen was crying and told the Skills Trainer, “I want to die.” Shortly thereafter, the teen requested a shower, and the Skills Trainer allowed it and then moved on to doing other tasks. As another less experienced staff member entered the area, the Skills Trainer reported feeling upset and needing a break. The Skills Trainer also told her relief the resident needed to get out of the shower and to “just keep knocking.”

The relief reported to investigators “never having supervised residents by herself in the past.” It was only her second shift on duty with residents. Also, the Skills Trainer did not inform her relief of the teen’s self-harm or statements about wanting to die.

The relief staff continued to knock, but had limited options to reach out for help from other staff because she lacked a walkie-talkie.

Trillium policy dictates that “residents in the bathroom are to be checked every 15 minutes, with a verbal response required.”

However, a total of 40 minutes had elapsed by the time the Skills Trainer returned and notified the supervisor. Entering the bathroom, the teen was found to have hung himself with an article of clothing.

Assessing the Farm Home’s Role
Multiple supervisors and managers at the Farm Home reported concerns about the Skills Trainer’s ability to maintain boundaries with clients; she was at the time of the incident on a “final written warning.” The Skills Trainer told investigators, she “did not like reading the residents’ background, treatment plan, or Advanced Behavior Directives, which include important information about mental health diagnoses and recommended interventions.”

The DHS notice stated that another staff member, “acknowledged the Skills Trainer previously expressed that the resident who committed suicide reminded her of her sibling,” and during the period of the incident she, “provoked the resident by incorrectly stating she searched the resident’s room because she wanted to ‘see the reaction.’”

The investigation of the suicide concluded that “the Skills Trainer neglected the resident’s care by failing to provide the care necessary to maintain the physical and mental health of a child in care.”

The Farm Home serves among the highest risk adolescents in the state; there was also a suicide at the facility in 2011.

Media and Management Responses
The Oregonian and The Gazette-Times reported on the suicide and subsequent investigation, stating the resident’s death resulted from neglect by Trillium’s “employees,” and that staff routinely falsified records to hide the fact they were not properly performing bed checks.

However, Trillium Family Services President and CEO Kim Scott said in a community letter, “In fact, the investigation identified one employee with a substantiated claim. There were no findings regarding any other employees or the organization as a whole.”

He also claimed that the investigator who found they were falsifying records, “retracted that finding.” Scott added the investigator had incorrectly read the chart.

“We do want to clearly communicate that we disagree with the findings of the state’s investigation as reported in the [Oregonian] article and are in the process of a formal appeal.”

It appears there is an argument that the circumstances spurring the investigation were isolated, rather than part of a pattern.

Next Steps
In the community letter Scott said, “We all understand [The Oregonian] article as written, will cause great concern for our families and partners who have trusted us with the safety and care of their children.”

Trillium is currently in the process of appealing the findings of OAPPI’s investigation as well as the intent to revoke their license to operate a child care agency.

Scott went on to say that the Intent to Revoke, under the new Senate Bill 1515, is a required action by DHS. “At the same time, we are working with our partners and legislators to modify SB1515 to allow the DHS Director more authority and discretion in issuing the intent to revoke.”

State Senator Sara Gelser, sponsor of SB 1515, declined to comment by press time.

By Anthony Vitale and Regina Pieracci