An investigation found “individual and systemic problems” that may have contributed to the death two years ago of a 22-year-old man with mental and physical disabilities under the care of Lamoille County Mental Health.
Disability Rights Vermont issued its report late Wednesday afternoon reviewing the Dec. 5, 2017, death of Jordan Machia.
“Of greatest concern,” the report states, “is the lack of capacity in Vermont to obtain and retain highly trained and professional home care staff to provide consistent and safe care to people with disabilities able to live in the community with appropriate supports and staffing.”
The case was brought to Disability Rights Vermont’s attention by Machia’s family, according to staff attorney A.J. Ruben. The report stated that Machia was reportedly sick for a few days prior to his death, but his shared living provider did not report that to Lamoille County Mental Health or his physician.
“There is a history of the shared living provider not being dutiful in making and/or keeping doctor’s appointments for Jordan when needed,” according to the report.
For example, according to the report, Machia’s shared living provider “routinely” failed to provide required monthly documentation regarding the administering of medication.
The report also makes a series of recommendations for how designated community mental health agencies and the Department of Disabilities, Aging and Independent Living “train, monitor and supervise staff who provide care for vulnerable adults in community/home settings.”
However, Ruben said that Machia’s situation stands out.
“While we did find a bunch of what we thought were policy violations and issues with care,” Ruben said, “we believe this is an anomaly.”
According to the report, Machia had been receiving support services at Lamoille County Mental Health and Amici Associates, and lived with support workers in Duxbury. Lamoille County Mental Health did not respond to request for comment Thursday.
Machia had been diagnosed with autism spectrum disorder, anxiety and atopic dermatitis and obesity. He also had “self-injurious behaviors, aggression toward others” and limited ability to communicate with others, according to the report.
In addition, the report stated, he had an “extensive history of property damage and assaultive behaviors” at his home placements.
At the time of his death, Machia was under the supervision of a public guardian from the Office of Public Guardian.
In 2011 he was placed in a shared living home when his mother felt he could no longer be safely cared for in her home. In October 2016 he was placed with a new shared living provider when his current Barre City home provider could no longer manage his behavior by himself.
The new provider also had difficulty caring for Machia, resulting in Machia being placed in a “crisis bed” operated by the Vermont Crisis Intervention Network in November 2016, where he remained for 26 days.
That’s when he moved to a new shared living provider in Duxbury where he stayed until his death, according to the report. At this facility, Machia was being supervised by two caretakers at all times. During the night, one would sleep while the other remained awake.
The report stated that the shared living provider who was awake found Machia unresponsive at 3:45 a.m. on Dec. 5, 2017, and instead of immediately calling 911 and starting CPR went to get the second caretaker from another part of the house.
“It is unknown if this decision not to attempt CPR initially contributed in any way to Jordan’s death,” according to the report. “Had a 911 call and CPR begun immediately, the outcome may have been different.”
The shared living provider did call 911 after determining that Machia was not breathing and had no pulse, but did not start CPR, stating that they opted not to do so because Machia “was not warm and there was no pulse.”
Emergency medical personnel pronounced Machia dead at 4:07 a.m., the report stated, two minutes after arriving at the scene. A medical examiner determined his cause of death was bronchitis complicated by pneumonia.
There was at least 20 minutes with no CPR attempted by the shared living provider or the overnight support staff person,” according to the report. “That does not include the amount of time that it took the overnight support staff person to get the shared living provider to respond
to Jordan’s room.”
Also, the report stated, the disability rights organization said it could not find any documentation showing the shared living provider or the overnight support staff person received basic first aid training or CPR certification.
“If Jordan was in fact not ‘warm’ when discovered, as the shared living provider reported, then the question arises of how long Jordan had not been snoring before he was actually checked on,” according to the report.
According to the report, overnight staff were supposed to observe and provide assistance to Machia throughout the night.
“The home share provider had some failings,” Ruben said. “But it also appeared that he was being paid by Lamoille County Mental Health, and they were responsible for doing the oversight.”
While Machia moved into the Duxbury home in late November 2016, by the spring of 2017, according to the report, Lamoille County Mental Health had concerns about whether it was a suitable placement for him.
The report shows that the mental health agency tried to get the shared living provider to complete and submit paperwork on time.
“However,” the report states, “the records were equally clear that these efforts were ineffective, that the shared living provider continued to fail to adhere to documentation requirements with no apparent consequences.”
“Our report does not say that whatever negligence or violations were the direct cause of Jordan’s death,” Ruben said. “But we found lots of instances of rules being violated and best practices not being followed that may have contributed.”
The report recommended that LCMHS consider requiring CPR certification for all shared living providers and their support staff.
“Not to make this mandatory is contrary to providing a safe and protected home environment for future clients in any home placement,” the report states.
It also recommended that LCMHS create clear policies to guide shared living providers on when it is necessary to consult with a medical provider about a change in a client’s health, “no matter how insignificant the shared living provider may consider it to be.”
“It’s about funding,” Ruben said. “We think Lamoille County Mental Health knew the home care provider was not conforming to the rules, and they would have put in place a new shared living provider if they had one avaiable — but I think they didn’t do that because they could not find someone else to do the work, and the result was this tragedy.”
