For five days and five nights, Paige Elizabeth Lunsford — a severely disabled teen — retched “like a waterfall,” could not eat and thrashed about in an “educational center” staffed with teachers, nurses and a doctor.
Paige was sick, and getting sicker. But caregivers did not send her to a hospital. Instead, they bound her wrists, ankles, biceps and waist with restraints to keep her from flailing.
Paige, nonverbal due to autism, could not ask for help. And none came.
Blond, pigtailed Paige, the child of Margate residents, died at the Carlton Palms Educational Center in July 2013, baking with fever, 10 days after she was sent there. A victim of medical neglect, according to the Department of Children & Families, she now rests beneath a small grave marker etched with musical notes and linked hearts.
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An autopsy determined that the 14-year-old succumbed to dehydration, the result of a severe but treatable infection.
Her death spawned the 140th DCF neglect or abuse probe involving the Lake County home since 2001 — there have been eight more reports since then — and yet, the facility has never paid a fine and never been disciplined.
On Friday night as the Herald was preparing to publish Paige’s story, the Agency for Persons with Disabilities, or APD, which oversees programs for disabled people, filed an administrative complaint against Carlton Palms, this time involving a separate neglect allegation.
A copy of the complaint provided to the Herald, redacted to obscure the names of those purportedly responsible, says the agency seeks a $10,000 fine and a moratorium on new admissions.
The state has tried this before, only to back away from imposing fines or cutting off admissions to Carlton Palms.
As for the staffers directly involved in Paige’s care: Dr. Robert Lynch and a nursing supervisor, Bonnie Clugston, remain under investigation by the state Department of Health, said Barbara Palmer, APD’s director,
They also remain on the job, despite Palmer’s efforts to have them removed. “We asked them to fire him, and the nurse, and they declined,” Palmer told the Herald.
Carlton Palms’ director, Tom Shea, did not return calls from the Herald. Lynch did not return calls, either. Clugston declined to comment.
Through their attorney, the Lunsfords declined to discuss their daughter’s death. “My clients are so devastated by the events surrounding Paige’s death that they have no words,” said lawyer Lisa Levine.
Paige was among about 500 children who died of abuse or neglect in Florida over the past six years after the state had received complaints about a caregiver — in this case, the center itself. Their stories are detailed in a Miami Herald series, Innocents Lost.
“To think of Paige’s last moments on Earth in so much misery breaks my heart,” said Deborah Linton, the Florida head of The ARC, a national advocacy group for people with disabilities. Linton said she brought up her concerns about Carlton Palms two years ago when Palmer was named APD’s director. “Carlton Palms is a huge issue. We told her then this is one of the things that will come back and bite you in the ass one day.”
Amid a spate of sexual assaults involving disabled people, Florida began a “Zero Tolerance Initiative” in 2003 aimed at stanching the abuse and neglect of people who cannot fend for themselves. State law contains a “bill of rights” for disabled people, which includes the right to “humane care” and “to be free from harm.”
Under its licensing and regulatory authority, APD can fine homes where abuse or neglect has occurred. It also can suspend or revoke their licenses.
What the agency can’t do is force the homes it licenses to fire people — so long as they haven’t been convicted of a crime.
Palmer said she wants legislation to give her agency the authority to act when DCF has found a caregiver to be abusive — even without a criminal conviction.
“We have to have these protections in place,” she said.
High ranking amid complaints
In the most recent budget year, the state paid Carlton Palms about $25 million to care for disabled individuals, an APD spokeswoman said. Despite the scores of abuse allegations, the home was given the highest ranking among “intensive behavior” providers licensed by the state.
Until Friday, APD administrators had filed two administrative, or licensing, complaints against Carlton Palms — the most recent of which, in October 2012, initially sought a moratorium on admissions, citing “multiple acts of physical violence to the residents.”
Both of the administrative complaints were withdrawn with no penalties imposed, the agency said.
“What we’ve tried to do here,” Palmer said, “is instead of fining people and saying ‘Don’t do this anymore,’ put in place things that must improve so the facility will get better.” She said the agency has used a carrot, not a stick, because Carlton Palms accepts as clients children and adults who are considered among the most difficult to manage.
But, Palmer added, Paige’s death “is the third strike, as far as I’m concerned.”
While fending off sanctions, Carlton Palms and its corporate parent, Advoserv, have actively supported the GOP-majority Legislature. Since 2010, they have contributed about $72,000 to the Republican Party of Florida, along with $500 and $1,000 donations to the campaigns of dozens of individual Republican lawmakers and four Democrats.
Paige, who was a twin, stopped breathing at about 7 a.m. on July 6, 2013. She went into full cardiac arrest. Caregivers said they called for an ambulance immediately. Paramedics said Paige “was already in rigor mortis” when they arrived, records say.
At least four agencies looked into Paige’s death: DCF, APD, the Department of Health’s Child Protection Team and the Lake County Sheriff’s Office.
DCF’s investigation concluded that Paige died due to the “medical neglect” of Lynch, who was her doctor, and Clugston, a nurse who oversees facilities in four states.
The Child Protection Team, or CPT, arrived at a similar conclusion: “There is no evidence that the medical and nursing staff acted in accordance with the standards of practice of the State of Florida in rendering this child safe care.”
The team added: “This child should have been taken to the hospital at an earlier point to be evaluated.”
CPT staff also criticized the home for repeatedly restraining Paige in violation of state laws that govern the use of restraints. “The decision to restrain a person,” the report said, “must be made with extremely careful deliberation, and in accordance with the laws of the state of Florida. When the staff elects to do so, it must be with a written doctor’s order, for a prescribed time period, and with the availability of continuous nursing observation.” The words “written doctor’s order” were underlined for emphasis.
“There are no records forwarded that show these guidelines were followed,” the report added.
And there were other problems. Detailed nursing and medical records — which might have shed light on Paige’s care — apparently did not exist, the CPT report said. “These are fundamental standards of nursing practices ... In the absence of such documentation, the assumption is the work had not been done,” a report said.
A video recording of Paige’s final hours was accidentally deleted, Carlton Palms administrators told police.
Open bleeding wound
Tucked among the rolling hills of rural Lake County, Carlton Palms is considered a “comprehensive transitional education program.” The state pays it about $150,000 yearly per-client, one of the highest bed rates in state government, to care for children, adolescents and young adults with complex behavioral challenges.
When Paige died, records show, the home had been investigated by DCF for abuse or neglect allegations at least 139 times since 2001; 92 complaints involved adult residents, while 47 pertained to children. Paige became number 140. All of the alleged victims suffered from some type of developmental disability, such as mental retardation, autism or cerebral palsy.
Among the 47 children’s reports, three were verified, including one allegation that a child had been physically abused, records show. DCF found some evidence to support another 13 reports, but not enough to verify them. Ten of the adult complaints also were verified. The agency found some evidence to support another 23, records say.
At APD, regulators filed complaints, and twice settled with a promise from facility administrators to do better.
In 2010, for example, three disabled residents — identified as J.K., T.F. and R.T. — were physically abused, the state charged. J.K. was beaten so badly that a tooth was knocked out. On Sept, 1 of that year, T.F. sustained “an open, bleeding wound which required medical attention” after being struck in the head, a complaint alleges. Then, the next month, R.T. was allegedly punched in the chest.
The APD sought $3,000 in fines in an administrative complaint for the abuse cases. As part of a settlement, though, APD waived the fine, Carlton Palms admitted no wrongdoing, but promised to retrain its staff.
As the 2010 complaint was being settled, reports about abuse of residents continued. In January 2012, a Carlton Palms caregiver reportedly ordered a disabled resident, R.G., who was making noises to “shut [his expletive] mouth” before he punched the man in the stomach. Another employee left the room rather than intervene, a complaint says. When the employee returned, the colleague was kicking and holding R.G. by the neck, the complaint said.
On April 18 of that year, a resident of one of the cottages told a Lake County deputy he saw a caregiver, Andre Mays, wrap his belt around his knuckles while he called a resident, R.T., “stupid.” The resident couldn’t see what happened next, but he “could hear the belt hitting” R.T. while the man pleaded with Mays to stop. “Don’t hit me!,” R.T. screamed, an administrative complaint said.
Another facility staffer yelled at Mays to stop the beating, the witness said, “but never bothered to get out of her chair to help,” a police report claimed. Mays was charged with abuse of a disabled person, but later acquitted.
In another incident in August 2012, deputies said caregiver Reginald Walters kicked a disabled child in the head when the youth — who has the intellect of a 5-year-old — would not stop “yelling and screaming.” When the youth continued to scream, a police report said, Walters choked him “until he was silent.” Walters left the scene, and two other caregivers “then completed the restraint.” Walters pleaded no contest to felony battery, and was placed on probation.
“Both employees stated they were in fear of their safety due to the bragging of [Walters] about how he carries a firearm in his car and isn’t afraid to use it,” Lake County Sheriff’s Office records said.
Palmer says her agency will not tolerate resident abuse. “There is no excuse for that,” she said. “Our job is to protect the most vulnerable people in the state.”
At first, APD sought a one-year moratorium on admissions following the four reported 2012 abuse cases. The complaint led to a settlement, dated Dec. 19, 2012. The terms: The moratorium on admissions was abandoned, and, once again, Carlton Palms acknowledged no wrongdoing. Carlton Palms agreed to maintain “continuous” video monitoring of the facility “to assure the safety of its staff and residents.”
But when Paige died a half-year later, all but one hour of the video detectives requested of Paige’s last night “had been accidentally deleted when [administrators tried] to copy it for the investigation.” The one hour detectives were given showed “nothing unusual.”
“That was totally unacceptable,” said Palmer, the APD director. “I mean, I was furious.”
Before Paige was admitted to Carlton Palms on June 26, 2013, she lived in a Coral Springs group home. Paige’s disability, and the self-injurious behaviors it engendered, made her particularly challenging to supervise, records show. She wore a protective helmet, arm splints and special clothing to prevent her from harming herself.
Medical records contained a red flag: Paige’s behavior could deteriorate badly if she was in pain or sick.
“Everyone was saying Paige had been sick since July 1,” a caregiver told DCF. Its review of the teen’s death details her final days:
▪ July 3: Paige, a supervisor told police, had already been sick for three days, vomiting violently. The supervisor “advised she never saw a nurse check on the child” — nor did she see Paige eat. That day, the supervisor “tried to give the child chicken broth, but she would not eat it, and she would not drink,” a DCF report states.
▪ July 4: “The child [vomited] within a minute or two after she drank some Gatorade.” A supervisor “called the Director of Nursing as she did not know what to do. She was advised ... to keep the child on a liquid diet and to contact the clinician about restraints. She never saw the Director of Nursing come to see the child.”
▪ 7/5/2013: A note in the charts that afternoon said: “Individual given Gatorade and cookies, refused cookies but drank the Gatorade. Vomited after last sip. Supervisor notified, individual cleaned.”
Paige vomited 25 to 30 times that night. A clinician and nurse were notified, but “neither one came by to check on Paige.” A supervisor told detectives Paige vomited “constantly, like a waterfall.”
Convinced that Paige may have been faking, caregivers repeatedly restrained the child, according to detailed records reviewed by the Herald. Staffers interviewed by authorities all denied harming the teen. “The child was doing a very good job of harming herself,” one supervisor, Kathleen Evans, told authorities.
On her last night, Paige was moved from her bed, and she was restrained in a chair, tethered by her wrists, ankles, biceps and waist, using a “locking belt,” according to reports.
That Friday night, Lynch, the facility doctor, visited Paige, a DCF review said. “On his way out of the exam,” the report said, “the child vomited.”
Lynch “made the conscious decision” not to hospitalize the teen, records say, because he felt it would be traumatic to have to restrain her to get her to an emergency room to administer fluids. “He said that they didn’t want Paige to be put through any more torture by having to strap her down and subject her to needles in the arm,” the girl’s mother wrote in a statement.
In an interview with authorities, a supervisor said “there is nothing she would do differently, given the opportunity. ...She followed protocol.”
Paige’s death was not reported to DCF until five days after the teen died — contrary to a pledge to report abuse allegations immediately.
The allegations of abuse continue. Last January, another Carlton Palms employee, Kenyatta Devon Hill, was charged with aggravated abuse of a disabled adult after she tossed 165-degree scalding water from a Styrofoam cup onto a resident, causing second-degree burns to the man’s chest and stomach, sheriff’s office reports say. Hill is awaiting trial.
After Paige’s death, the home was placed on a “plan of remediation.” A series of negotiations that followed led to an agreement, largely concerned with better facility management and the video cameras that settled the 2012 abuse cases. “The quality of the video images captured must be improved,” Palmer wrote in an April 22, 2014 letter.
Last month, a Carlton Palms resident broke his arm so badly that doctors believed surgery would be required. The boy was agitated, charged toward staff and kicked a cabinet before being restrained, a report said. DCF investigated, a spokeswoman said, finding the injury did not result from abuse.
The caregivers will be retrained.