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DEATHS IN IOWA'S INSTITUTIONS

2005
August 22:Inspectors Recommend Feds Cut Off Funds To Iowa Institution
2001
April 6: Staff Told Not to Talk to Investigators About Resident's Death
July 11: Restraint Death Ruled A Homicide
August 16: Parents Sue Facility And Staff For Boy's Restraint Death

Staff Told Not To Talk To Investigators About Resident's Death
By Dave Reynolds, Inclusion Daily Express
April 6, 2001

WOODWARD, IOWA--They just didn't feel like it.

That's the reason staff members at Woodward Resource Center, an institution for people with mental retardation, refused to talk to investigators from the federal Protection and Advocacy program over the death of a resident last month.

They just didn't feel like it.

"It always seems to us that people tend to look for a scapegoat," said Jan Corderman, president of the union that represents state employees.

Members of Iowa's Protection and Advocacy were on the campus investigating the suspicious death of Larry Tielebein last month. Tielebein, 45, died after his arms and legs were placed in restraints.

Employees at the facility apparently are still stinging over the 1998 investigation into the death of Woodward resident Donna Miller, who drowned after being left alone in a bathtub. Officials with the Department of Inspections and Appeals said the institution had failed to protect Miller and the other residents, according to an article from today's Des Moines Register.

It turns out that the state employees at Woodward Resource Center and another facility in Glenwood do not have to talk to Protection and Advocacy. Iowa law dictates that they only have to cooperate with criminal investigators, internal investigators and the Department of Inspections and Appeals.

It also turns out that, under Iowa law, the Department of Inspection and Appeals, which is charged with inspecting ICF/MRs (Intermediate Care Facilities for the Mentally Retarded), cannot impose fines on either facility, or cut their federal Medicaid funding. The inspections department can only make recommendations to the Iowa Department of Human Services.

And over the past ten years, the inspections department has recommended that funding be cut from Woodward on several occasions, because of serious violations in standards of care, including failing to protect residents from harm. In 1992, it made that recommendation after three residents died over a six month period.

But, Human Services did not stop Medicaid money from flowing to Woodward.

Why not?

The reporter points that because the Iowa Department of Human Services operates Woodward and Glenwood, in punishing either facility it would be punishing itself. "By agreeing to cut off Medicaid, the department would be denying itself the money it relies on to run the two hospitals," he writes.

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Restraint Death Ruled A Homicide
By Dave Reynolds, Inclusion Daily Express
July 11, 2001

WOODWARD, IOWA--Larry Tielebein was killed.

The official finding by the state's medical examiner is that the 45-year-old man, who had mental retardation and cerebral palsy, died from "compression or positional asphyxia".

In other words, he suffocated to death.

Tielebein suffocated to death on March 18 while staff members restrained him on a kitchen floor at Woodward Resource Center, a state-operated institution housing 270 people with mental retardation.

And even though Tielebein's death is officially listed as a homicide, no charges have been filed.

Investigators say that on the day of his death Tielebein began kicking, hitting and spitting at staff members. Several responded by putting Tielebein into a device that held his wrists to a waist belt. They then held him facedown on the floor for at least 15 minutes.

According to the official reports, the staff refused to release Tielebein even though he began sobbing and repeatedly said he was sorry. It was only at the point where one staff member noticed that Tielebein's skin was turning dark blue that they turned him over and tried unsuccessfully to revive him.

The Des Moines Register reported today that the institution has now been cited for more than two dozen violations related to restraints. Included in those citations is the finding that the staff ignored the program that had been devised for Tielebein, who had lived at the facility for 25 years. That program instructed the staff to discontinue the use of restraints when Tielebein was "calm" - which the facility defined as when he "says he's sorry, stops spitting, uses a quiet voice and (is) able to have regular topics of conversation."

In spite of those reports Woodward superintendent Dr. Michael Davis told the paper that the violations were only related to documentation problems.

The Iowa Division of Criminal Investigation is continuing to investigate the case.

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Parents Sue Facility And Staff For Boy's Restraint Death
By Dave Reynolds, Inclusion Daily Express
August 16, 2001

MASON CITY, IOWA--On Tanner Wilson's first day at Gerard of Iowa care center two years ago, staff member Lori Ingham tried to "take him to the ground". During the attempt to restrain him, Ingham succeeded in breaking the boy's leg.

On February 9 of this year, a year and a half after being admitted to the mental health facility, Wilson died while being restrained in a "routine physical holding".

He was 11 years old.

Officials have ruled the cause of death as asphyxiation -- he suffocated to death -- and are considering it a homicide.

One of the employees allegedly involved in restraining Wilson when he died was none other than Lori Ingham. She now faces a charge of child endangerment in connection with the death.

This Tuesday, Tanner's parents, Robert and Karen Wilson, filed a lawsuit against Ingham and fellow employee Jeremy Witt, along with Gerard Treatment Programs and an affiliate known as Nexus Inc..

According to the Des Moines Register, the suit claims Ingham and Witt "used unreasonable and unnecessary force in restraining and eventually killing" the boy. It also charges Gerard, which was being paid $9,000 a month to care for Wilson, with failing to properly train and supervise its employees.

The Wilsons are asking for unspecified compensatory and punitive damages. They say they do not want other parents to go through what they have gone through.

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