For Mentally Ill,
Death and Misery
By: Clifford J. Levy
New York Times, April 28, 2002
Randolph Maddix, a schizophrenic who lived at a
private home for the mentally ill in Brooklyn, was often left alone to
suffer seizures, his body crumpling to the floor of his squalid room. The
home, Seaport Manor, is responsible for 325 starkly ill people, yet many
of its workers could barely qualify for fast-food jobs. So it was no
surprise that Mr. Maddix, 51, was dead for more than 12 hours before an
aide finally checked on him. His back, curled and stiff with rigor mortis,
had to be broken to fit him into a body bag.
At Anna Erika, a similar adult home in Staten Island
entrusted by the state to care for the mentally ill, three other residents
had previously jumped to their deaths when a distraught Lisa Valante, 37,
sought help. But it was after 5 p.m. and, as usual, the residents, some so
sick they cannot tie their shoes, were expected to fend for themselves. No
one stopped Ms. Valante, then, from flinging herself out a seventh-floor
window.
Sometimes at these homes, the greatest threat can be
the person who sleeps in the next bed. Despite a history of violent
behavior, Erik Chapman was accepted at Park Manor in Brooklyn. After four
years of roaming the place with a knife, Mr. Chapman stabbed his roommate,
Gregory Ridges, more than 20 times. At last, Mr. Chapman was sent to a
secure psychiatric facility. Mr. Ridges was sent to Cypress Hills Cemetery
at the age of 35.
Every day, New Yorkers come face to face with the
mentally ill who have ended up on the streets since the state began
closing its disgraced psychiatric wards more than a generation ago. Mr.
Maddix, Ms. Valante and Mr. Ridges were among thousands more who ended up
in dozens of privately run and state-regulated adult homes in New York
City.
A yearlong reporting effort by The New York Times,
drawing upon more than 5,000 pages of annual state inspection reports, 200
interviews with workers, residents and family members, and three dozen
visits to the homes show that many of them have devolved into places of
misery and neglect, just like the psychiatric institutions before them.
But if The Times's investigation found that the
state's own files over the years have chronicled a stunning array of
disorder and abuse at many of the homes, it discovered that the state has
not kept track of what could be the greatest indicator of how broken the
homes are: how many residents are dying, under what circumstances and at
what ages.
The Times's investigation has produced the first full
accounting of deaths of adult home residents. At 26 of the largest and
most troubled homes in the city, which collectively shelter some 5,000
mentally ill people, The Times documented 946 deaths from 1995 through
2001. Of those, 326 were of people under 60, including 126 in their 20's,
30's and 40's.
At two of the largest homes, Leben Home in Queens and
Seaport Manor in Brooklyn, roughly a quarter of the 145 residents who died
were under 50. The Times's analysis of the deaths used Social Security,
state, court and coroner's records, as well as psychiatric and medical
files.
The analysis shows that some residents died roasting
in their rooms during heat waves. Others threw themselves from rooftops,
making up some of at least 14 suicides in that seven-year period. Still
more, lacking the most basic care, succumbed to routinely treatable
ailments, from burst appendixes to seizures.
Some of the hundreds of deaths undoubtedly stemmed
from natural causes and were unavoidable. Studies have found that the
mentally ill typically have shorter life expectancies than the general
population, because they have difficulty caring for themselves and are
more prone to health problems. The average age of death in the overall
survey was 63.
There are few extensive studies on death rates of the
mentally ill in facilities like adult homes. But Dr. E. Fuller Torrey, a
psychiatrist who is a nationally recognized expert on mental illness and
mortality, called The Times's analysis disturbing.
"It would certainly suggest a fair number of
deaths that were premature," said Dr. Torrey, who is executive
director of the Stanley Medical Research Institute in Bethesda, Md., and
is familiar with the adult home system in New York City. "There is no
question that if these people were getting better care and more skilled
care, they would be living longer. And this poor care leading to death is
going to cut right across the age population. It also means that people
who are 70 are dying prematurely."
In the end, whether the residents were in their 20's
or 70's, it is impossible to know just how many of their deaths could have
been prevented. The only other accounting of the dead seems to be on Hart
Island in the East River, where scores of adult home residents are buried
in the mass graves of potter's field.
Officials at the State Department of Health, which
regulates the homes, acknowledge that they have never enforced a 1994 law
that requires the homes to report all deaths to the state. Asked for
records of any investigations into deaths at the homes, the department
produced files on only 3 of the nearly 1,000 deaths.
None of the suicides were among the three. Even the
fatal stabbing of Mr. Ridges at Park Manor went unexamined by the
department. The city medical examiner's office said it had not received a
single inquiry in recent memory from state inspectors regarding an autopsy
of an adult home resident.
Neither Gov. George E. Pataki nor his health
commissioner, Dr. Antonia C. Novello, would comment on The Times's
investigation. Their aides said a deputy health commissioner would speak
for the administration.
Presented with The Times's findings, the deputy
health commissioner, Robert R. Hinckley, said the department would examine
"ways to better investigate those deaths that are reported to
us."
To that end, Mr. Hinckley said the state would issue
a regulation alerting the homes that it would strictly enforce the 1994
law on reporting deaths.
"We want facilities to follow the law, and we
are redoubling our efforts to get them to report all deaths," he
said.
As of Friday, seven weeks after Mr. Hinckley's
promise, the department had still not issued the regulation.
About 15,000 mentally ill adults — most of them
poor, many of them black and Hispanic — reside in more than 100 adult
homes in the state, the majority in the city and its suburbs. Some are now
larger than most psychiatric hospitals in the nation.
The reality of the homes is far from what was
envisioned. In the 1960's, New York, like other states, decided to shutter
or sharply scale back its psychiatric wards, where patients often
languished for decades.
When the profit-making adult homes offered to shelter
the discharged patients, the state embraced the idea. Federal disability
money was used to pay the homes, which would provide meals, activities and
supervision. The homes would bring in outside providers for psychiatric
and medical care.
The state was responsible for making sure it all went
well.
But from the start, problems surfaced. No one knew
about them better than the state itself, which for 30 years has issued
damning inspection reports and then all but ignored them.
State investigators across those three decades
described many of the homes as little more than psychiatric flophouses,
with negligent supervision and incompetent distribution of crucial
medication. At one, Brooklyn Manor, the staffing was so sparse that a
resident was put in charge of the entire place on one evening, a routine
2001 state inspection report shows.
In more than 100 inspection reports from 1995 through
2001, investigators frequently noted filthy and vermin-ridden rooms in
some homes, and disheveled and unbathed residents in others. They cited
administrators for poor, sometimes fraudulent, record-keeping involving
residents' money and care. A 2001 state inspection of Garden of Eden in
Brooklyn found the operator to be "routinely threatening
residents."
In a 1990 overview of adult homes, the Commission on
Quality of Care for the Mentally Disabled, a small state watchdog agency,
rated half of the homes that it surveyed in the city as poor. Ten years
later, the agency came to the same conclusion.
But the formal reports get at only part of the
system's failures, according to The Times's investigation.
The investigation reveals several of the homes to be
medical mills where the operators and health care providers pressure
residents to undergo treatment — even surgical operations — they
neither need nor understand in order to earn Medicaid and Medicare
billings.
The homes are typically run by businessmen with no
mental-health training. A 1999 audit by the State Comptroller's Office
aimed at evaluating the regulation of adult homes found that the
Department of Health had done little to scrutinize the people it licensed
to run them.
The homes are staffed largely by $6-an-hour workers
who dispense thousands of pills of complex psychotropic drugs each day. At
one home, Ocean House in Queens, social workers said a medication worker
was basically illiterate.
The homes are not required to have professional staff
on duty overnight. Multiple visits reveal that often only the janitors,
and possibly a guard or two, remain.
Nathaniel Miles, a former porter at Surf Manor, a
200-bed home in Coney Island, recounted two scenes last year that he
called typical: on one night, he had to stanch the heavy bleeding of a
resident who had had a seizure and fallen in a bathtub. Down in the lobby
on another night, he had to chase after a woman who had threatened to kill
herself and had run from the home.
The notion that residents would be limited to those
who might, with help, enter the work force or join a community was
abandoned almost from the outset. The state's own files show that the
residents include severe schizophrenics, manic-depressives and others who
have no hope of achieving self-sufficiency. Visits to the homes reveal
that some residents hole up in their rooms for days at a time. Others can
be found in smoking rooms or hallways, suffering psychotic episodes. Some
are shuttled back and forth to psychiatric wards.
And many, it is clear, do not survive.
At the largest homes, one person died every three to
eight weeks on average from 1995 through 2001, The Times's analysis shows.
At the 361-bed Leben Home, 14 of the 66 dead were under 50 years old. At
the 346-bed Seaport Manor, 24 of the 79 dead were under 50.
"Seaport is no more than a warehouse," a
50-year-old resident wrote to her sister on Christmas Day, 1998.
"There are an unusual number of deaths among middle-aged people
here."
Less than two months later, the resident scrawled
"Evil wins" on the wall of her room, swallowed an overdose of
pills and placed a plastic bag over her head, according to toxicology
reports from the medical examiner's office and interviews with Seaport
workers. The home's report to the state shows that Seaport failed to
disclose the true details of her suicide, saying only that she was
discovered dead in her bed. The state never looked into it anyway,
according to its own files.
To do an inventory of the deaths, though, is to
appreciate residents who had passions and triumphs and who had strived to
find their own place in the world.
Jonathan Miller, sweet and gentle, traded baseball
cards from his room at an adult home in Queens called King Solomon. He
died there, of a heart attack, during a heat wave in July 1999. Mr.
Miller, 35, was not discovered until the smell brought a worker to his
door. The home waited until night to remove his body, workers said, then
they cleared his room of the baseball cards he loved. At his wake, his
family wept in front of a coffin that had to be closed to hide what had
happened to his corpse.
"These people are just given little value by
either the state or the adult homes or the mental health providers,"
said George Gitlitz, who has spent a decade visiting the homes and urging
the state to improve conditions on behalf of the Coalition of
Institutionalized Aged and Disabled, one of the few advocacy groups for
adult home residents. "They are seen as dollar signs — as property
— and not as human beings."
The sorry history of New York's adult homes and their
oversight extends over decades and multiple administrations. And New York
is not entirely alone. Other states placed discharged mental patients in
similar facilities. In 1989, after surveying homes in several states, a
Congressional committee called them "a national tragedy."
Not all the dozens of homes in New York City are
disastrous. Some are clean and staffed by kindly people who try to help
the mentally ill find their way. Yet all the places are troubled by the
same systemic problems, like untrained workers and gaps in supervision.
The homes are also costly. The government spends an
average of $40,000 a year on each resident through federal disability and
Medicare and Medicaid payments. That adds up to $600 million annually in
taxpayer money.
Yet even as public money pours into the system, the
government does little to hold the homes accountable. Over the years, few
operators have been meaningfully punished, despite amassing records of
misconduct, state inspection reports and interviews show. Albany,
lawmakers concede, has consistently chosen to avoid the looming question:
If you close the homes, where will the mentally ill live?
And so for decades, thousands of them have been
living in broken-down former hotels and rooming houses. Police and fire
department records make clear that emergency workers are frequent
visitors, routinely responding to 911 calls about psychotic episodes,
unfettered chaos and dead bodies.
Merciless Season
A Sweltering Summer, Rooms Like Ovens
The summer of 1999 was one of the most oppressive in
memory in New York City, day after day of soaring temperatures and pleas
from health officials for the public to take precautions.
At the Leben Home for Adults, a brick building on
45th Avenue in Elmhurst, Queens, the rooms could heat up like a furnace.
Originally built to house offices for an airline parts factory, the
structure is poorly ventilated, making it hotter inside than outside in
the summer.
The more than 350 residents at Leben, like many
mentally ill people, are vulnerable to the heat because of their
medication and poor general health. Most also had no income beyond their
modest monthly disability checks, and could not afford to buy
air-conditioners or pay the additional fees that Leben's operator, Jacob
Rubin, charged to run them.
Mr. Rubin received more than $3 million a year in
government money to operate the home, even though state inspections deemed
it neglect-ridden. As Mr. Rubin ran the air-conditioner in his office
there, closing the door to keep it cool, workers said, many residents went
without fans.
It was an exceptionally tough summer for Michael
Bonner, who had taken to hiding away in his room for days at a time, with
no one at the home trying to coax him out.
Mr. Bonner had schizophrenia and depression and had
been in and out of homeless shelters, psychiatric wards and adult homes
for much of his 52 years. There had been times when he found stability. He
had worked as a porter at La Guardia Airport and as a clerk at a
department store. He had liked to show up at his uncle's home in the
Bronx. "Surprise!" he would say before bounding in. But his
disease always seemed to win out.
By 1999, it had become overwhelming.
For weeks at Leben that summer, workers said, they
appealed in vain to Mr. Rubin to install new air-conditioners and fix
broken ones. The rooms were suffocating, and resident after resident was
getting sick.
Mr. Bonner remained in his room all day on Aug. 16,
when the outdoor temperature reached the mid-80's. At some point, Mr.
Bonner's roommate saw that he was in distress and ran into the hallway
looking for help. Dennis Lloyd, the director of security and recreation at
the time, responded.
"The man is in convulsions, foaming from the
mouth," Mr. Lloyd said in an interview. "His body had to be like
108 degrees, 109 degrees, such a fever. It was hot that day. To touch him,
oh my God. His body was burning up. When E.M.S. came in, we were ordered
to soak towels in cold water, to wrap his body. But it was too late. He
died in the hospital."
After working at Leben for 14 years, Mr. Lloyd left
last year and took a job at a nursing home. He said he agreed to be
interviewed about Leben because he felt the public needed to know about
the conditions there.
In Mr. Bonner's case file at Leben, it was scrawled
only that he had hyperthermia, a spike in body temperature. His uncle,
Nathan Goods, said an administrator had told him that Mr. Bonner had died
of a heart attack.
Leben never notified the State Department of Health
about the death. That was not surprising. Instead of enforcing the 1994
law requiring the homes to report all deaths, the department asks the
homes to report deaths only from "other than natural causes."
The homes, which have no medical credentials, get to make that
determination, and they usually determine deaths to be natural.
Mr. Goods eventually went to Leben to pick up his
nephew's few possessions, which the home had put into a trash bag.
"He was just another poor soul who didn't have a family with money
who could watch him and protect him," Mr. Goods said.
His death at Leben was not unique, though. July and
August were the deadliest months at the 26 adult homes in The Times's
survey in four of the seven years. As at Leben, most of the other homes do
not run air-conditioning unless residents pay an extra $25 to $150 a
month. The operators say the state does not pay them enough to provide it
free.
Few months took as great a toll as July 1999, when 17
residents died.
Three weeks before Mr. Bonner died, Stephanie Dinardi,
40, was found by her roommate naked on the floor at Leben and was dead
when the ambulance arrived.
But the ambulance workers knew they would be back.
"During the summers, we were constantly at Leben for heat
cases," said Chris Jute, one of the workers who responded that day.
The state knew the reasons. Psychotropic drugs can
reduce sensitivity to heat and the ability to sweat. The mentally ill are
also less likely to take precautions, such as drinking fluids, and are
prone to diabetes and other diseases aggravated by heat. One of the
state's own psychiatrists, Dr. Nigel Bark, found in a study that
psychiatric patients had twice the risk of dying during heat waves as the
general population. He concluded that the "risk can be
eliminated" with air-conditioning and other precautions.
The State Office of Mental Health has provided
air-conditioning in the state's psychiatric hospitals for more than two
decades. The office, the agency with the most expertise in addressing the
needs of the mentally ill, has little role in overseeing the adult homes,
which shelter three times more mentally ill people than the psychiatric
hospitals.
Asked why the adult homes were not air-conditioned
and what precautions were taken by the Department of Health in the summer,
Mr. Hinckley, the deputy health commissioner, said regulations required
the operators to ensure that residents "remain comfortable" when
the temperature is above 85 degrees.
While many hospitals and nursing homes run
air-conditioners, Mr. Hinckley pointed out that the state did not require
them to do so, either.
Mr. Rubin would not comment. In May 2001, after The
Times published two articles detailing malfeasance at Leben, the state
forced him to surrender his license and leave the industry. The home,
under new management, was recently renamed Queens Adult Care.
Muriel Sachs, who endured a quarter-century at Leben,
would not live to see Mr. Rubin go. Ms. Sachs, 71, had respiratory
problems and the misfortune of being assigned a room on Leben's third
floor, its highest and hottest.
She was a fixture at the home, wandering the halls
and showing off an old photograph of herself with a dapper man she
imagined was her husband. She had survived a lobotomy and more than two
decades in psychiatric wards before the state shut them down. "We
have no other alternative than referring her to you," a social worker
wrote to the newly opened Leben in 1974.
She would grow old at the home. Then, on July 6,
1999, several things conspired against her in Room A317. The outside
temperature hit 101 degrees and Mr. Lloyd, the longtime security director,
said the workers on duty that night refused to check on the residents on
the third floor because it was stifling.
Room A317 not only lacked air-conditioning. The fan
also did not work because the room's electricity had accidentally been
shut off, Mr. Lloyd and other current and former workers said.
In the middle of the night, Ms. Sachs got out of her
bed, perhaps to seek help. She did not get far. At 6:50 a.m., she was
found face down on the floor of her room, dead of heart failure, according
to police records.
"She passed away because of the suffocating
heat," recalled a former janitor, Arsenio Cabrera, who was on duty
that morning.
Mr. Cabrera, Mr. Lloyd and other former Leben workers
said they kept silent because they feared losing their jobs.
"Everything was covered up," Mr. Lloyd said.
Mr. Rubin notified the Health Department about Ms.
Sachs's death, without mentioning the heat, according to department
records. A state inspector wrote a note saying that she could not follow
up anyway because she was too busy, the records show.
Ms. Sachs was Jewish, and occasionally attended
religious services. A group called the Hebrew Free Burial Association will
provide a proper Jewish burial in the city for anyone who cannot afford
it. It requires a phone call. Ms. Sachs was sent to potter's field. No
mourners or headstone or prayers. Only a burial number, 34943.
Threat to Themselves
A Trail of Suicide, a Lack of Answers
Both Melvin Ryan and Lisa Valante had long been
besieged by schizophrenia. Their voluminous psychiatric records told of
histories of bizarre behavior, of an inability to care for themselves, of
periods of depression so relentless they could not pull themselves out of
bed for days.
They had already tried to kill themselves when they
were sent by a state hospital, Rockland Psychiatric Center, to the Anna
Erika home in Staten Island within two months of each other in the late
1990's. Less than two years later at the home — deemed by the state to
be the appropriate place for them to live — the two would finally
succeed in ending their lives.
Mr. Ryan, 51, jumped out a seventh-floor window. Less
than three weeks later, Ms. Valante, 37, did the same. They were the third
and fourth residents of the home to commit suicide that way in four years.
After Ms. Valante's death, the operator of the home installed guards on
some windows, he said, but not on others, including the one that Ms.
Valante had jumped from.
In the state's headlong drive to make its psychiatric
wards obsolete, officials have publicly maintained for 30 years that the
adult homes are a satisfactory substitute. The thinking is this: with
psychotropic drugs, residents do not need close supervision. They will see
therapists regularly, and when a crisis arises, they will be sent to a
psychiatric ward.
In the wake of that thinking lies a roll call of
suicides that, in recent years, includes but is not limited to:
• Vadim Sapojnikov, 26, who left Park Manor, went
to his family's home for a visit and leapt from a fourth-floor window.
• Eliezer Sulsona, 42, Sherri Cohen, 38, and Joan
Ciancimeno, 49, who jumped from New Haven Manor, Sanford Home and Park Inn
in Queens.
• Robert Tricarico, 41, who leapt from Lakeside
Manor in Staten Island.
• Lavar Murphy, 22, and Charles Osdin, 83, who
hanged themselves at Wavecrest in Queens and Riverdale Manor in the Bronx.
• Myrna Millington, 61, and Fu Jun Ho, 45, who
jumped from Anna Erika before Ms. Valante and Mr. Ryan.
All these suicides went uninvestigated by the state
inspectors who regulate the homes, according to their records. Had the
suicides occurred at a psychiatric hospital or even a prison, they would
have routinely prompted inquiries.
Ms. Valante had been sick since her 20's and was
estranged at times from her parents, who live in Florida. As her illness
worsened, she often refused to bathe and insisted on wearing only one set
of clothing, a printed housedress over a long black outfit.
Mr. Ryan had lived with his elderly parents in Harlem
for years, until they could no longer care for him. Despite his battles
with schizophrenia and drug abuse, he had the face of a mama's boy,
angelic and unlined, and a sinewy body that harked back to his days as a
high school track star.
By the time they got to Rockland Psychiatric Center
in 1997 and 1998, the two had been hospitalized numerous times after
psychotic, often suicidal, episodes, and it seemed clear that their
chances of leading stable lives were slim.
Mr. Ryan was put on a suicide watch at one point at
Rockland, and often told his psychiatrist that he heard voices threatening
to lynch him, according to his treatment records.
Ms. Valante wrote all over the walls of her hospital
room, a paranoic graffiti about death and evil. A psychiatrist quoted her
in her treatment records as saying, "I wish I could just die and rest
in peace and eternity."
Still, Mr. Ryan and Ms. Valante could not remain
there forever. The state encourages hospitals to save money by stabilizing
patients and discharging them. With few exceptions, New York does not want
to provide long-term psychiatric care.
So the two were sent to Anna Erika to stay.
Like many adult homes, Anna Erika has been cited by
state inspectors for serious violations in recent years. The home is one
of the largest in New York, with 427 beds, including a significant
population of elderly people, some without mental illness. But at one
point, inspectors charged that it did not have a single qualified case
manager to supervise residents, according to a 1999 state report.
The therapists who came to Anna Erika to treat
residents did what they could, but there were not enough of them and the
home could also easily get rid of them if they complained about
conditions.
Soon after Mr. Ryan and Ms. Valante began living
there, they hunkered down in their rooms. Over the next year and a half,
both had psychotic episodes, were hospitalized and then were determined
well enough to return to the home.
By the summer of 2000, Mr. Ryan was refusing
medication, and his therapists considered hospitalizing him again. He
asked to move from a room on the second floor to one on the seventh. The
home agreed.
He told his social worker on Sept. 13 that he was
afraid to get out of bed and was considering voluntarily going to a
psychiatric ward, according to his treatment records. Two days later, at
7:20 a.m., the police said, he opened the window in his room and stood on
the ledge. Then he jumped.
Less than three weeks later, Ms. Valante would
follow. Her psychiatrist had also been considering hospitalizing her,
according to her treatment records. Shortly after 8:30 p.m. on Oct. 3, Ms.
Valante went to see her social worker, who had an office on the seventh
floor, according to interviews and records. As usual after business hours,
no one was there. She paced the hallway, then walked into a room, opened
the window and jumped.
Vincent Sirangelo, Anna Erika's operator, said the
home had done nothing wrong in caring for the two.
When asked for evidence to show that the home had
been closely monitoring Mr. Ryan and Ms. Valante or had even known that
they were in crisis, he declined to provide any. He said Anna Erika
"had fulfilled its obligations."
"We did our own internal investigation," he
said. "There was no reason that surfaced why they committed
suicide."
The Ryan and Valante families heard nothing from
state officials after the suicides, and got only a single phone call from
Anna Erika administrators.
"They said, `We just wanted you to know that
your daughter is dead,"' recalled Ms. Valante's mother, Gertrude.
"Just like that. I went out of my mind when it happened. And they
wouldn't give me any answers."
Threat to Others
A Stabbing Ends a Rebuilt Life
Gregory Ridges, 35, called his mother every morning
from Park Manor, a storefront home on Coney Island Avenue near Prospect
Park in Brooklyn. He loved to tell her that he was setting off for his
part-time job as a custodian. "I'm going to make the doughnuts!"
he would exclaim, riffing on that old television commercial. Then he would
put on his uniform and shoes, which he had carefully laid out the night
before.
When he returned to the home he would let his mother
know that the doughnuts had been made, a routine she cherished. Once
plagued by paranoia about himself and his family, her son had slowly
gotten better. He was one of the few adult home residents who held a job,
and he took great pride in it.
The first boy of 10 siblings, Mr. Ridges had a
special place in his mother's heart. She called him Big G, and loved his
sense of humor. So did workers and residents at Park Manor, a home for 62
mentally ill people.
In the late 1990's, Mr. Ridges lived there with two
other men in a dusky room not much bigger than a sleeper on an Amtrak
train. He and Sanford Lall got along. Their other roommate, Erik Chapman,
had an obsession with knives and threatened to kill them both.
Mr. Chapman was as feared around the home as Mr.
Ridges was liked. One worker refused to be alone with him. Other residents
recalled violent outbursts when he used illegal drugs and rejected his
psychotropic medication.
Even his family was afraid of him. Before going to
Park Manor, he stabbed his sister and stepfather, beat up his brother and
attacked his father-in-law so viciously he was in the hospital for weeks.
Psychiatrists had noted Mr. Chapman's violent tendencies, yet he was
accepted at Park Manor in the mid-1990's and stayed for four years.
If people like Ms. Valante and Mr. Ryan did not
belong at adult homes because they were a threat to themselves, Mr.
Chapman exemplified a different sort of danger.
The screening of residents can be lax at the homes,
in part because it is at the discretion of operators who have no mental
health training and are running commercial enterprises. Since an empty bed
means no money, some homes are willing to accept almost anyone, records
and interviews show.
As a result, fighting among residents and other
violence in the homes are not uncommon. Killings are, yet when they have
occurred, they have gone unexplored. In 1989, for example, two women were
killed in separate cases at Leben, and their deaths were not classified as
homicides for months. The crimes were never solved.
At Park Manor, everyone immediately knew who the
killer was. What went unexamined was why he had been able to remain at the
home despite ample evidence that he was dangerous.
Mr. Chapman, now 33, began having psychotic episodes
in the early 1990's while living with his family in Brooklyn. "He
used to always carry a knife and brass knuckles," said his brother,
Charles Chapman. "Was I scared of him? Most definitely. He just likes
to physically attack you."
In 1994, after stabbing his sister, Erik Chapman was
hospitalized at Kings County Hospital Center. "Patient remains very
guarded and evasive," a psychiatrist wrote in his records. "This
together with history of violent assaultiveness suggest he is a risk and
dangerous to others." Less than two months later, Kings County
discharged him.
From 1996 through 2000, Mr. Chapman lived at Park
Manor. After one psychotic episode in late 1998, he went to Maimonides
Medical Center, where psychiatrists repeatedly noted his hostility toward
his roommates and his refusal to return to the home, according to his
treatment records.
"Admits to possibly wanting to hurt men," a
psychiatrist at the hospital wrote. Asked on a form whether Mr. Chapman
had homicidal tendencies, another psychiatrist wrote a question mark and
then, "Suggested hurting his perceived persecutors." Among his
delusions: he believed his Park Manor roommates were coughing up blood on
him.
After two months at the hospital, he was discharged
back to Park Manor. Soon after, inspectors cited the home's operators for
doing almost nothing to examine his psychiatric history or address his
needs, according to a June 1999 state report. But the inspectors never
followed up.
That was not out of the ordinary. As with other
homes, inspection reports portrayed Park Manor as in disarray, to no
avail. At one point, they noted, a college student was volunteering as the
home's case manager for all 60 or so residents.
It was a testament to Mr. Ridges that he had been
able to turn his life around there. He arrived at Park Manor in 1994 after
several psychiatric hospitalizations. After a shaky start, he settled in.
In the last year of his life, he focused on everyday issues such as how to
budget his paycheck — his doughnut money, he called it — so he would
not spend it all at once.
But he did have to contend with his roommate. His
mother, Hattie Fee Ridges, said that her son often complained that the
home would not do anything about Mr. Chapman. Mr. Ridges told her that he
had asked for his room to be switched, but had been turned down.
Mr. Lall, their other roommate, said Mr. Chapman
often instigated arguments with him and Mr. Ridges. Mr. Lall recalled in
an interview how Mr. Chapman once shoved him against a wall and held a
knife to him. "He said, `If you don't behave yourself, I'm going to
kill you,' " Mr. Lall said.
On a Thursday in June 2000, Mr. Ridges returned from
his job and went to his room. He encountered Mr. Chapman and the two
apparently argued over rap music, the police said. Mr. Chapman pulled out
a brown and gold folding knife. He lunged, stabbing Mr. Ridges more than
20 times in the neck, sternum and arm.
"Me and Greg Ridges didn't get along," Mr.
Chapman told the detectives who arrested him.
When Mrs. Ridges did not receive her customary phone
call from her son that day, she called the home. An employee told her
everything was fine. Wary, Mrs. Ridges went to the home that night, and no
one would let her in. Several hours later, police officers showed up at
her apartment and told her what had happened.
A few days later, she locked the door to her son's
former room in her apartment. To this day, she rarely enters it. "I
just can't bring myself right now to part with his things," she said
recently. "I miss him."
Nearly two years after the killing, no one in an
official capacity has delved into the home's role. Not the State Health
Department, which regulates the home, nor the police, nor the Brooklyn
district attorney's office, which focused only on prosecuting Mr. Chapman,
who was found unfit for trial and sent to a psychiatric facility.
Otis Cue, Mr. Chapman's stepfather, said that he felt
great sorrow for Mr. Ridges's family and that he hoped some lessons could
be learned that might help prevent violence at the homes. But Mr. Cue
added that no officials had contacted him about his stepson's history.
For now, there are only denials.
Park Manor's operator, Simon Halpert, said Mr.
Chapman had no history of violence, was well liked at the home and had
never caused the slightest trouble. "Anybody and everybody who comes
in this door has had a thorough screening," Mr. Halpert said.
He said Mr. Ridges had never asked to have his room
changed.
Maimonides Medical Center, which treated Mr. Chapman
during his last hospitalization, said it never discharged patients who
were a threat.
The only state agency saying it looked into the
killing was the Office of Mental Health. It did so, it said, because
therapists who worked at a clinic run by the office treated Mr. Chapman at
the home. The office said it agreed with Mr. Halpert. It would not release
a copy of its investigation, saying it was protecting the privacy of the
mentally ill.
"We never had a problem with him in his
behavior," Mr. Halpert said of Mr. Chapman. "He was very polite,
always polite."
Casualties of Care
Ignoring the Signs Pointing to Trouble
On a spring Sunday in 2000, Ann Marie Thomas began to
die at Elm-York, a 286-bed home tucked away near a ramp to La Guardia
Airport.
Ms. Thomas, 60, was having chest pains and trouble
breathing, according to interviews and records, and the workers there told
her to relax. The next day, a nurse who visited the home told Ms. Thomas
she was having an anxiety attack. By that night, the vice grip around her
chest had tightened.
"She kept saying, `I can't breathe, I can't
breathe,' and clutching her chest in pain," said Terry Lipiro, a
resident of the home at the time. Several workers confirmed her account.
Until then, Ms. Thomas had been relatively sturdy,
the home's hallway Ann Landers, a gush of gossip and advice. Her delusions
quelled by medication, she grasped at a normal life, doting on a boyfriend
named Harvey, ordering in Chinese food and listening to Elvis Presley.
On Tuesday, Ms. Thomas saw a medical doctor, Mathaiah
Ramaiah, who also diagnosed anxiety, and Ms. Thomas received no treatment,
according to interviews and records.
"She had these chest pains, and they should have
paid more attention to her," said Dhandai Dhanraj, a worker at the
home at that time.
By Tuesday night, a roommate, Elizabeth Szalkiewicz,
became alarmed and called Ms. Thomas's sister for her.
"I think I'm having a heart attack and they
don't believe me," Ann Marie Thomas told her sister, Josephine, on
the phone. "I think that I'm dying."
Josephine Thomas said she then called employees at
the home, who assured her that her sister was fine.
A short while later, Ann Marie Thomas lay down on the
floor of her room and removed all her clothes, hoping to find relief from
the sensation that she was suffocating, according to interviews with
residents and workers. Ms. Thomas stayed there, naked, and began to feebly
pray.
The next morning, Ms. Thomas was found dead of heart
failure, still in the same undignified position.
In interviews, executives of Elm-York said workers
had closely monitored Ms. Thomas and reported that she was not in
distress. They would not say which workers, or provide records detailing
when they checked on her. "If there had been chest pains, 911 would
have been called," said Robert Amsel, the home's administrator.
Mr. Amsel said the home provided such good care that
"less than 10" residents died from 1995 through 2001.
The Times documented roughly 110 deaths of Elm-York
residents in that period, largely from death records kept by the Social
Security Administration.
After being given a list of those names, Mr. Amsel
said that many of them were of people who were no longer residents when
they died. He would not say which people he was referring to.
Dr. Ramaiah would not comment.
Josephine Thomas complained to the State Commission
on Quality of Care for the Mentally Disabled, the small watchdog agency.
She charged that her sister would have lived had she received proper
supervision.
Thirteen months later, without interviewing her, the
agency told her that it could find no evidence that the home had done
anything wrong or that Ann Marie Thomas had ever complained of chest pain.
The commission might have found some evidence if it
had examined the report filed by the ambulance workers who responded to
the home. "Patient's roommate states that patient collapsed last
night, 12 hours ago, but no one at the facility responded to her calls for
help until this a.m.," the report said.
In a way, Ms. Thomas's death underscores the most
basic shortcomings in supervision and care found by The Times's
investigation at many of the homes. Yet she was certainly not alone. John
Miller and Randolph Maddix were just two more residents who died
unattended after signs of distress were ignored, records and interviews
show.
Mr. Miller, 47, a resident of Park Inn in Queens,
died of a ruptured gangrenous appendix in 1997 after complaining of pain
for three days, according to his brother. The state took no action; his
family is suing the home in State Supreme Court in Queens, charging that
neglect led to his death. The home's lawyers would not comment.
At Seaport Manor in Canarsie, Brooklyn, even the
untrained workers realized that Randolph Maddix was too sick to be there.
During his two years at Seaport, ambulances took him to Brookdale
University Hospital and Medical Center more than 40 times after he had
seizures at the home, according to hospital records.
But whenever the workers said they suggested to the
home's administrators that he be sent to a nursing home, the
administrators demurred. It would mean an empty bed. And profits always
seemed to trump other considerations at Seaport, which the state has long
rated one of the city's worst adult homes.
Less than a year after Mr. Maddix entered Seaport, a
therapist wrote in his case file that he should be placed in a "more
suitable environment" because he was paranoid and refusing to eat.
State inspectors also suspected that Mr. Maddix
should not be there. In an inspection report in July 1999, they cited the
home for failing to address his problems and send him to a facility with a
"higher level of care," but did nothing else.
So Mr. Maddix stayed, and suffered. On several
occasions, workers said he had seizures while watching television in the
smoking room, then writhed and tumbled to the floor. He broke his elbow.
He smashed his face. He bloodied his eye.
"He couldn't do anything on his own," said
Andy Cadet, a former Seaport worker. "As time went by, the seizures
started increasing, and getting worse and worse."
Seaport's operators would not comment. Last year,
after The Times began an investigation of Seaport, the state said it would
move against the home, even though it had known for decades about grievous
problems there. Last month, the operators agreed to surrender their
license, and the state is now considering whether to try to install a new
operator or close the home.
Mr. Maddix had had seizure disorder since he was a
teenager. One of the few things that gave him pleasure was smoking cigars
and drinking coffee on the Coney Island Boardwalk as he stared at the
water. But for much of his life, he could barely function.
He occasionally had an aide assigned to him at
Seaport during the day, but the aide left before dinner. He was then
deposited in his room, where he sometimes suffered seizures alone, in the
dark. His roommate, who was partly blind and often delusional, sat by,
unknowing.
"There wasn't anybody there at nighttime to
watch out for him," said his mother, Mildred Maddix. "There
wasn't anybody. Just him and God."
His last visit to the hospital was on Oct. 9, 1999.
After a seizure, he was found unconscious in his wheelchair. Dried blood
from a finger-length laceration crusted the right side of his face. As
always, he was returned to the home.
Less than two weeks later, he went to the bathroom
connected to his room in the early evening and had another seizure,
falling between the toilet and the bathtub, workers said. He was
discovered dead the next morning still next to the toilet.
At Seaport, the discovery of a dead resident was
almost routine. The usual practice was followed: the home reported only
that Mr. Maddix was found unresponsive and then pronounced dead, never
telling the state the full details of what had happened.
As with the deaths of so many other mentally ill
residents of adult homes, the state never investigated anyway.
FAIR USE NOTICE: This
page contains copyrighted material the use of which has not been
specifically authorized by the copyright owner. Global Action on Aging
distributes this material without profit to those who have expressed a
prior interest in receiving the included information for research and
educational purposes. We believe this constitutes a fair use of any such
copyrighted material as provided for in 17 U.S.C § 107. If you wish to
use copyrighted material from this site for purposes of your own that go
beyond fair use, you must obtain permission from the copyright owner.
|
