December 18 , 2005

LEEANA'S LAST DAY – HOW INCOMPETENCE AND NEGLECT LED TO A TODDLER'S DEATH AT A STATE-FUNDED GROUP HOME

By Kevin Rennie - Hartford Courant
Leeana Calendario might have died of any of the complex and chronic illnesses she developed as an infant. Instead, 13 days short of her third birthday, Leeana died of something quite ordinary - respiratory failure as a result of a clogged breathing tube.

That's the medical explanation.

Just as accurate is that the Bridgeport toddler's death is the result of incompetence and neglect at a state-funded group home for medically fragile children.

A confidential, 40-page report by the Special Investigations Unit of the Department of Children and Families says Leeana died at Trumbull House, a privately operated facility licensed and largely funded by DCF. The agency placed Leeana there despite her family's apprehensions about the quality of care there. Leeana suffered from a multitude of problems, including a brain injury common to premature babies, chronic lung disease and tracheomalacia, a weakness in the walls of her airway that required a tracheostomy and a breathing tube in her throat.Many Trumbull House staff members themselves worried, too, that they would be unable to care for such a severely disabled child. Because of the group home's tense working climate, however, and earlier acts of retribution against staff who protested certain policies and practices, most employees were reluctant to challenge the appropriateness of the child's placement. One nurse who did complain to the program director was told to quit if she could not work under the supervisor who'd approved Leeana's placement at the home, an affiliate of St. Vincent's Medical Center in Bridgeport.

On her final day, Leeana's care was assigned to a licensed practical nurse who had worked at Trumbull House for six weeks and whose only previous experience as an LPN was a six-month stint at a long-term care facility for the elderly. In the child's final moments of most acute need, nurses in the home panicked as she struggled to breathe through a clogged tube in her airway. One grabbed an oxygen mask and placed it over her face, a useless gesture to aid someone who breathes not through her nose or mouth but through a tube in her throat. Perhaps the only thing that makes this story more outrageous is its familiarity. Yet again, DCF, which gets $800 million a year in taxpayer money, has failed in its most basic mission: to keep children safe.

Yet again it has failed to provide the standards of care it insists parents meet.

And yet again, it is hiding behind its worn shield of confidentiality (read, secrecy), asserting that is in the best interests of the child.

We know more now than we often do when catastrophe strikes and DCF mans the barricades. The confidential report tells the story.

Leeana's Family

The youngest of four children, Leeana was born prematurely at 29 weeks. She was repeatedly hospitalized. Because of her severe respiratory issues, she needed the tracheostomy tube to breathe, and the tube required frequent suctioning to rid it of secretions. Despite her medical issues, Leeana, at nearly 3, was already learning to sign and could let her family know when she wasn't feeling well or when something was wrong with her trach.

Leeana was "beautiful, intelligent, lovable," her mother, Elizabeth Serrano, said during an emotional interview.

Leeana spent most of her short life in hospitals in New Haven, New Britain and Bridgeport, including a year at the Hospital for Special Care in New Britain. While Leeana was there, Serrano said, the family went to court to compel DCF to provide transportation for them between their Bridgeport apartment and New Britain three times a week because Serrano has no driver's license. DCF also said it would provide transportation when Leeana was placed at Trumbull House, but the family said that never happened.

More recently, Serrano said she would drive with no license to Trumbull to see her daughter. By all accounts in Leeana's complicated story, her family was deeply and constantly involved in her care. Serrano, her sister and her mother all learned how to operate Leeana's breathing apparatus and how to suction the baby. And the extended family pitched in to help care for the disabled child.

Even before the girl was born, Leeana's mother, who suffers from depression, and her children moved in with the children's grandmother, Ana Serrano, who became the children's legal guardian. After Leeana's birth, Ana became her guardian as well. DCF helped the family find a larger apartment in Bridgeport, Elizabeth Serrano said.

But their relationship with the state agency was a two-edged sword. When a nurse walked into the apartment and found Leeana's 10-year-old sister suctioning the girl, DCF quickly moved the child out of the apartment into Yale-New Haven Hospital.

Department spokesman Gary Kleeblatt said last week that the treatment plan for Leeana to go to Trumbull House "was agreed to by medical professionals, and the mother agreed to the placement."

Both Serrano and her mother said in separate interviews that DCF pressured them to move Leeana to Trumbull House. Both women said that although it wasn't stated, it was clear to them that if they didn't agree, they would lose custody of Leeana.

The System DCF Created

DCF has long been under pressure to find appropriate in-state facilities for severely disabled children whose families cannot care for them. For years, the department has sent these children out of state. Five years ago, DCF began working with the non-profit St. Vincent's Special Needs Services, which had previously operated group homes only for adults, to establish and run homes for children. Facilities such as these are the creation of DCF, and without its patronage, they would be out of business. DCF licenses them, regulates them and is often their only customer. When something goes wrong, DCF has little interest in pointing out failures. The failures of places like Trumbull House are DCF's failures, too.

According to St. Vincent's website, it has established two homes - in Stratford and in Trumbull - where children "benefit from a home-like atmosphere lovingly created by skilled and caring nurses and direct care counselors." The Stratford facility has about 14 children of varying ages and medical needs, while Trumbull House has six. St. Vincent's has been receiving $326 a day per child from DCF.

And although loving may be their aspiration, the overall impression employees gave DCF investigators was of two facilities rent with tension, backbiting and incompetence. What's more, the report by DCF's investigators raises questions about the homes' ability to handle even children less fragile than Leeana. Although the major thrust of the report is Leeana, it also addresses problems in care for another child at the facility. Nathan, 17, had broken his foot, but because of confusion in getting the foot x-rayed, the staff didn't learn of the fracture for nearly two weeks.

The report's findings include dozens of "program concerns," such as:

• The first of two training sessions for the staff on Leeana's machinery was given "on paper," the day before the machinery - and Leeana - arrived at the home. The second session, the only one when the handful of staff who attended could actually use the ventilator, "only covered turning the machine off and on. It was reported that there was no segment that covered troubleshooting, which is necessary given the potential for an emergency."

• The majority of the nursing staff "had very little medical experience with the pediatric population and had little to no trach emergency care experience."

• Leeana's records were "consistently poorly and inaccurately managed. This negligent pattern was encapsulated by the sloppy and erroneous nursing practices" that should have been identified by supervisors and staff.

In addition to respiratory problems, Leeana had MRSA, a highly contagious strain of bacteria that is immune to antibiotics. According to the report, there was no documentation that the staff had been "well educated and in compliance with the necessary precautions outlined by the consulted physicians" to deal with MRSA. A number of employees told DCF investigators how worried the staff was to learn that Leeana had MRSA. Yet, one nurse told the investigators that the nurse who took care of Leeana on the day she died had, on one occasion, "picked a small particle out of Leeana's trach without using gloves and then picked up another resident without washing his hands."

Many of the investigators' individual concerns are disturbing. In their totality, they are a damning indictment.

Nursing Supervisor's Qualifications

Much of the report focuses on the inadequacies of registered nurse Laura Bivona, the nursing supervisor for the Stratford and Trumbull homes. Another staffer, longtime licensed practical nurse Barbara Oleynick, told investigators that she had expressed serious concerns about Bivona's lack of qualifications to St. Vincent's Program Director Harry Schaefer, but that her comments were ignored. Oleynick said Schaeffer told her to resign if she couldn't get along with her boss. Oleynick told the investigators that "she had only cared for Leeana three times but had concerns that her nebulizer was broken in the past, her room was unkempt, medication containers were dirty, the house was unkempt, and there were two different infection-control standards and it was not clear to staff which to follow."

Bivona had been hired by St. Vincent's seven months before Leeana was admitted. She had 27 years in nursing, she told investigators, 15 of which were spent running her own home day-care for children. She was a nurse at a school for special needs children, had worked part-time, per diem, for Milford's health department, and had been a camp nurse and a substitute school nurse.

Though the report makes her sound like the chief decision-maker for on-site care, Bivona saw it differently. She told investigators she was "primarily focused on making the residents get to school on time." (Classes for the residents of both group homes were held at the Feroleto Children's Development Center in Trumbull Corporate Park. Trumbull House was located in the same building in the corporate park.)

And although she was the one who determined that Trumbull House could handle Leeana, she was on a weeklong vacation starting the day after the girl arrived.

Bivona told investigators she was "not aware of any nursing concerns around Leeana's care."

She may have been the only one who was unaware.

Bivona could not be reached for comment.

Armando Rodrigues, assistant Stratford house manager, told the investigators, "many of the staff were reluctant to come forward with their concerns regarding Leeana for fear of losing their jobs." The investigators wrote Rodrigues "reported that Ms. Bivona told them not to say anything bad against the organization because they would shut down the program."

One nurse reportedly had her shift split in retaliation for standing up to Bivona over a patients-related issue at the Stratford facility.

The day after Leeana arrived, the staff determined someone would have to be assigned to the girl full-time. That would entail not only meeting her feeding, changing and breathing needs, but never letting her out of sight. Ana Serrano, Leeana's grandmother and guardian, said last week that when visiting Leeana, she sometimes would find the girl alone. Elizabeth Serrano said she walked into the home another night to find the tending nurse asleep.

Leanna's Last Day

On Sunday, April 17, licensed practical nurse Michael Borrelli arrived an hour late to work and was assigned to Leeana. As a caregiver for the child, he was sorely lacking in experience and, at times, showed lapses in judgment. On one occasion early in his six-week tenure at Trumbull House, Borrelli had appeared "dazed and confused during his shift," the DCF report notes. He said at the time that he "did not manage his diabetic condition that day." On another occasion, he had been reprimanded for smoking near Leeana.

The administrators did nothing to improve his limited skills. He told investigators he had "no special child-specific training in regards to Leeana." The report states he said he " `felt comfortable suctioning as he did a lot in school,' but reported having no experience with trach emergencies."

"He reported that he had past experience cleaning, removing and putting trachs back in, but he never had to do this with Leeana since they cleaned it during the third shift," the report says. But before she left at 2 p.m., nurse Barbara Oleynick told Borrelli three times to suction Leeana's breathing tube before he did so.

Four staff members were on hand that afternoon, but the numbers quickly dwindled: One left for the local emergency room to accompany a child whose blood pressure was dropping. Another was told by supervisor Bivona - who was in Stratford - to drive two patients there for haircuts. That left Borrelli and Agnes Georges, also a licensed practical nurse.

Georges reported that Leeana was watching "Barney" and Borrelli was attending to her feeding tube when she saw Leeana sliding down in her wheelchair. (The DCF report notes elsewhere that Leeana's highchair and wheelchair were both broken.) After Leeana slid for the third time, Georges said she placed the girl into her playpen. Leeana sounded "gurglie," Georges said. Before leaving the room to change the diaper of Susie, another patient, Georges said she told Borrelli to suction Leeana's breathing tube, the fourth time that day Borrelli had to be told to do so.

It's unclear exactly what time this was. Borrelli told investigators that although his memory of the afternoon was "vague," he thought that the time was between 3:30 and 4 p.m.

Borrelli told investigators he took Leeana into her room to suction her, but as he was doing so, he said, the girl started to cough and then flail. She turned red.

"She was kicking and moving about, making it difficult for me to give her the treatment," he said. "I noticed at that time she became flushed and then stopped breathing. I called for [Georges] to call 911. I gave her a few puffs of the ambu bag to which no air was being administered. I brought her out of her room to lay her on the table, at which point she lost consciousness." (An Ambu bag is a resuscitating device used to pump air into a patients lungs.)

According to the DCF report, "Ms. Georges stated that she did not hear Mr. Borrelli call her name until she came out of Susie's bedroom. She stated that Mr. Borrelli came out of Leeana's bedroom and Leeana appeared lifeless. Ms. Georges stated that she started screaming, `What happened?' "

Borrelli carried the child to her crib and started "compressions with the ambu bag to the trach. He reported that Leeana was fighting, tossing and turning." He tried to suction her again, "got nothing," picked her up and removed her feeding tube, according to the investigators. "He reported that before he got to Leeana's bedroom door, Leeana's eyes closed. He stated that he screamed to Ms. Georges that nothing was working, and Ms. Georges was screaming on the phone during the 911 call."

At that point, Kali Jones, the aide who had taken the two residents for haircuts, returned.

"Ms. Georges stated that she immediately noticed that the two residents that Ms. Jones left with were not present. She stated that it was later discovered that Ms. Jones left the two residents alone in the van during the crisis with Leeana."

During the emergency, Susie, the child Georges had been caring for, ran outside, unattended, into Trumbull Corporate Park.

"Ms. Jones came in and started screaming," Borrelli told investigators, "and someone mentioned getting the oxygen. [Borrelli] stated that Ms. Jones got the oxygen and hooked it up and she placed the oxygen mask over Leeana's face while he completed chest compressions. He stated that in hindsight, he realized that placing the mask over Leeana's face was futile since she had a tracheostomy. He reported that the police arrived shortly after and took over."

In her statement, Jones told investigators that it was Borrelli who placed the mask over Leeana's face.

Borrelli "reported that when the paramedics arrived, he thought that they took out Leeana's trach and took it with them. When asked why he did not take out the clogged tracheostomy tube, he stated, `I just didn't think to,' " the report says. Emergency technicians took Leeana to Bridgeport Hospital. At 6:07 p.m., she was declared dead.

Aftermath

After Leeana's death, administrators ran for cover. They fired Bivona, the scapegoat for their mismanagement, citing "deficient nursing skills and poor nursing leadership."

Bivona has been charged with medical neglect in violating numerous policies of the department's manual, and the report says her case has been referred to the state Department of Public Health, which licenses health professionals.

The DCF unit did not charge Borrelli with neglect because he received no formal training to care for Leeana, because Bivona said she had no concerns about his abilities, and because, at the time of Leeana's death, he tried to help her "to the best of his ability."

No criminal charges have been filed in the case. But lawyers Michael Stratton and Frank Riccio are representing the Serrano family in a wrongful death claim, and for what they say is a violation of the Patient's Bill of Rights.

DCF's Kleeblatt concedes that Leeana's placement in Trumbull led to a "terribly tragic outcome which everyone is upset about. It was a terrible result."

He said there were DCF caseworkers going in and out of the facility while Leeana was there, but he did not know how many visits, if any, Leeana's own caseworker made. He said there was a licensing inspection, though the DCF investigators' report indicates that the inspection occurred before Leeana arrived.

Given the investigation results, the inspection could not have been very thorough.

In an interview, child advocate Jeanne Milstein said, "The Child Fatality Review Panel is currently conducting an extensive investigation of Leeana's death. What we have learned in DCF's report was that the staff at St. Vincent's was unprepared, untrained and lacked the skill to care for Leeana.

"And worse," Milstein said, "DCF so lacks the capacity to understand the needs of children with complex medical conditions and developmental disabilities that they did not even check to see if the staff knew what they were doing."

Failure surrounded Leeana in her final weeks, and there's plenty of blame to go around. DCF should be held accountable for allowing a little girl who required skilled and experienced caregivers to be placed in a home that could not care for her. Her fate was determined the day she arrived.

And DCF, which continues to fail children, also continues to try to hide it from the public.

The investigation of Leeana was long and, it appears, mostly thorough. Of the 32 people questioned, however, only one was a DCF employee - Rosemary Whitaker, Leeana's DCF caseworker. Her role is reduced to a paragraph in the report, in which she states she had no concerns about Leeana's placement or care.

And the failures in the child-care system will continue. The workers who were alarmed clearly felt they could not turn to DCF for assistance. An anonymous complaint was not made about Trumbull House until after Leeana died.

Our policymakers share some blame, too. Caring for the most fragile children is complicated, and legislators often defer to state bureaucrats. Very few vocal constituents have business with DCF. Parents of the children in their care for medical reasons are often poor or consumed with the imperatives of participating in care.

DCF Commissioner Darlene Dunbar would not comment about Leeana's death. Kleeblatt, her spokesman, said Dunbar was not familiar with the details of the case.

He also said that the state has raised the rates it is paying the home. The rate now is $486 per day per child - a 50 percent increase - because, he said, the size of the nursing staffing has gone up "substantially" since Leeana's death. What's more, he said, "St. Vincent's has been extremely responsive to our suggestions."

There's usually a punishment attached to the incompetence that kills a child, but not in Connecticut government.

The only representative from St. Vincent's who would come to the phone to answer questions was their head of marketing, Virginia Smith. Smith said that as a result of Leeana's death, the facility has made changes in training for its staff. In addition, she said, St. Vincent's has been working with DCF to expand their program. Smith said St. Vincent's plans are to establish two new group homes for medically fragile children every year for the next four years.

Leeana's voice has been stilled. Others must now find theirs.

Copyright 2005, Hartford Courant