Case study: protection and advocacy for Colorado’s most vulnerable citizens 

The following case is being handled by The Legal Center’s Grand Junction office. Sadly, it is only one of many instances that demonstrate why protection and advocacy services are so important.

Louise’s mother called The Legal Center in great distress over her teenage daughter who was living in a Community Centered Board group home. Louise, who has significant physical and mental disabilities, was already underweight for her age and height when she entered the home. Within nine months, she had lost approximately 15 pounds, despite being prescribed a food supplement by her doctor.

The Legal Center began an investigation with interviews of the home’s program director, case manager, and other members of the staff. We also reviewed Louise’s medical record and the group home’s policies and procedures and other records. Patient records showed that Louise lost weight each month during her stay in the group home. We learned that the medication was frequently unavailable—sometimes for two weeks out of every month, because of an ongoing mistake in the ordering department that was never rectified. In addition, Louise sometimes refused the medication because she didn’t like certain flavors.  Her preferences were not taken into account and no effort was made to find a flavor she would accept. Louise’s doctor was never notified of her continuing weight loss even though by the end of her stay, she was close to starvation and her health was clearly at risk.

Louise’s mother had other concerns about the quality of her daughter’s care, but The Legal Center focused on the weight issue as being a striking case of multiple violations of the patient’s rights. We concluded that the case manager, the medical administration, and the program administration all failed in fundamental obligations to this resident. Violations of State regulations concerning medical administration in this case included: (1) error in the amount of the nutritional supplement to be administered; (2) erroneous entries deliberately made in the medical chart; (3) failure to notify the prescribing physician when the prescription was not fulfilled; (4) and failure to prepare incident reports as required by the home’s own policies and procedures. 

The Legal Center filed a complaint with Colorado Developmental Disabilities Services.  The complaint was referred by that agency to the Colorado Department of Public Health and Environment, where it is under investigation.

Louise’s mother removed her from the group home, fed her and cared for her until she reached a normal weight and then requested a return to her former place. The CCB responded that it had already filled Louise’s bed and that she would be placed on the waiting list. As part of the requested remedy, The Legal Center asked that the CCB identify a placement for Louise as soon as possible.

The client’s name and personal details have been changed to protect the family’s privacy.