UPDATE 9/24/2017 - DHHR report: No neglect, criminal charges in death of ResCare client by Giuseppe Sabella, Staff Writer GAZETTE MAIL

9/18/2017 - Jeremy Bush, 13, was the son of Mr. and Mrs. Freddie Bush of the greater Creston area

Death of teenager reveals shortfalls at Charleston facility

Giuseppe Sabella, Staff Writer GAZETTE MAIL

Staff members at a Charleston care facility often lost keys before a boy stole the facility's van and died in a wreck earlier this year, and an employee lied about checking on the boy just before he died, a state investigation has found.

Jeremy Bush, 13, lived at Woodward Children's Home, which is residential facility operated by ResCare, a company based in Louisville, Kentucky. Bush took the keys to a van and then crashed into a stone retaining wall. An employee later estimated Bush's speed at 70 miles per hour, according to a report from the state Office of Health Facility Licensure and Certification.

"As I made that snake curve I saw the van standing engine down and the back of the van positioned up and on fire," the employee was quoted as saying in the OHFLAC report.

ResCare, among other services, provides residential care to children with extreme mental and physical disabilities.

Employees lost the van keys two or three days before Bush's death, and the keys reappeared on the day he died, according to the report.

The home required employees to secure vehicle keys in a lockbox. However, staff members sometimes failed to follow procedure, the report states.

One employee said the facility's vehicles stayed unlocked while parked in the driveway, according to the report. Investigators found an unlocked vehicle at the home two days after Bush's crash.

When the staff did secure keys in a lockbox, they opened it with a "1-2-3-4-# or 1-2-3-4-* code," according to the report.

The facility housed four clients before Bush's death. In the report that followed, investigators declared the residents' health and safety were in "immediate jeopardy."

As part of an emergency plan of improvement, management agreed to make the code more complicated. Employees are also required to place vehicle keys in the lockbox, and to secure the lockbox key in a separate location.

ResCare clients require constant supervision. Employees have slept in the hallway to stay near residents' bedrooms, according to the report.

Still, the report said Bush escaped twice before the crash that led to his death.

On Jan. 29, he pushed out a window and left the home. According to the reports, it's not clear if employees notified Bush's guardian.

The employees then installed an alarm on Bush's bedroom windows — but he could still turn off the alarms or remove their batteries.

Bush then tried and failed to escape through a bedroom window on Feb. 7. Instead, he left on a bike and traveled to a convenience store, the report states.

Surveyors said the facility never identified Bush's behavior as a risk in his official support plan.

The home's new policy requires a tamper-proof alarm on every bedroom window, according to the report. "Staff will open and close windows daily to ensure that the alarms are working properly," the report states.

Along with providing constant supervision, ResCare employees are tasked with documenting daily activities. But staff members at the children's home failed to complete a form each time they left or returned with a child or vehicle, according to the report.

An employee last signed the vehicle sign-out form on March 12, even though someone used the van three days later.

One staff member lied on Bush's sleep chart the night of his death, according to the report.

According to the chart, she saw Bush awake at 8:15 p.m. The employee actually left her shift an hour early, at 7:01 p.m., according to the report. Bush crashed the van about 45 minutes later.

In their report, investigators said the faked chart made them question "the validity of other documentation completed by facility staff."

As a result of the investigation, the home's residential manager will now make random visits to the home. The clinical supervisor is responsible for reviewing incidents and ensuring that each report is investigated. There will also be a safety meeting each month, when the staff will review incidents and try to identify ongoing problems.

Investigators visited the home on April 25 and completed a follow-up report. They found no deficiencies, meaning the facility is in "substantial compliance" with federal regulations, according to an email from Allison Adler, a spokeswoman for the state Department of Health and Human Resources.

Adler said the job of OHFLAC investigators is to make sure health centers are following regulations and policies. "If OHFLAC determines referrals are necessary to law enforcement or professional boards, these referrals are made," she wrote.

Sgt. Mark Kinder of the Charleston Police Department announced an investigation after Bush's death in March. Kinder was unavailable for comment.

ResCare will not say whether it disciplined any employees of Woodward Children's Home. "We can't comment directly on employment questions due to privacy concerns," said Kristen Trenaman, a spokeswoman for the company, in an email.

She said ResCare investigated Bush's death in hopes of improving the quality and safety of his former home.

"We are deeply saddened when harm comes to any individual we serve," Trenaman wrote in the email.

Woodward Children's Home is among several ResCare facilities to face scrutiny in West Virginia. OHFLAC confirmed at least 30 complaints among 10 ResCare agencies in the state between 2012 and 2016.

The health department called on ResCare officials to gather in West Virginia for a meeting in April. State officials intended to "address the serious issues raised in the Gazette article," according to an internal email.

In a recent email, Adler said officials used the meeting to push for changes at ResCare.

"We continue to explore options available to help prevent these tragedies from happening in the future, including possible statutory changes," she wrote.

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