In May of 2008, a resident of Somerset was murdered in a nearby hotel. She had a long history of chronic drug abuse, prostitution, mental illness and seizure disorder. A resident of Somerset previously, she was jailed for drug possession and then paroled, re-entering Somerset January 23, 2008. Between readmission and her death, she chronically refused to take medication, persisted in drug use and frequently failed to return to the facility after curfew. The Illinois Department of Public Health (IDPH) investigated the facility subsequent to her death (Findings here) and found that the facility was negligent.
The report is an indictment of Somerset. It first details how disturbed and out of control Maratta was: frequent, recurrent medication refusal, multiple hospitalizations, continued use of drugs, and continued prostitution in the community. It doesn’t mention whether she participated in any therapeutic programming, but I would assume she refused or participated minimally. As a result of these problems, Maratta was on facility restriction. Despite this restriction, the facility allowed her sign out and enter the community. Consequently, the state cited Somerset for inadequate supervision of Maratta. In addition, the report notes that the parole officer was not adequately informed of on-going events by Somerset, precluding any intervention on his/her part. The facility also failed to file a missing persons report with the police (though the facility contends they did file a report). In short, the investigation concludes that Somerset did not supervise Maratta Walker and she was murdered.
I do not wish to defend Somerset. If she was placed on restriction, they should have enforced that restriction or at the very least been more aware of when she violated it and mounted a better response. The facility should have had a working relationship with the parole officer. If they failed to file a missing persons report, clearly they should have done so. However, looked at carefully, Maratta’s story—which is not atypical except that she was murdered— illustrates the difficulty the state has dealing with high risk, chronic psychiatric patients. Her case also illustrates the hypocrisy of blaming long term care facilities that the state inappropriately uses as both dumping ground and scapegoat.
Maratta was a difficult case. In her mid-forties, she had had decades of hospitalizations, treatment programs, residential placements and arrests and yet, despite endless intervention, she continued to use drugs and engage in prostitution. Worse, she was uncooperative with treatment, frequently refusing even medications to prevent seizures. Anyone with a lick of sense knows that she is simply going to continue to use drugs and prostitute herself if given the opportunity
So why was she given the opportunity? IDPH contends that Somerset shouldn’t have given her that opportunity and should have kept her restricted to the building. And here is where the problem lies: the state is placing on the facility an obligation to do what, in principle, only the state itself—and the judicial system in particular—has a right to do: take away an individual’s liberty. Yes, she is mentally ill and, in theory at least, under treatment. However, because simply labeling someone as mentally ill has historically been used to inappropriately take away individual rights (and often property), there is a century worth of law that very very strictly regulates the restriction of personal liberty in the name of treatment.
The only way the state can restrict Maratta’s liberty is to imprison her or have a judge court order her to a state hospital. Though arrested more than 35 times for multiple crimes, including slashing someone with a razorblade, the state penal system did not see fit to imprison her for any extended period. Was her mental illness construed as an extenuating circumstance? If so, then neither did the state see fit to place her in a locked state psychiatric hospital to ensure she obtained treatment and was not released until she was no longer a danger to herself or others. What the state did, through the system they have set up, is place her in a nursing home to be rehabilitated. And to provide supervision.
So despite the complete and total failure of all prior treatment programs, hospitalizations, judicial and penal interventions, Maratta is now Somerset’s responsibility. Somerset is required to provide treatment, though it cannot compel Maratta to take her badly needed medication. Somerset cannot compel Maratta to participate in therapeutic programming. The only thing the facility can do is restrict Maratta’s liberty, precisely what the state of Illinois has refused to do. That is, Somerset can take on the pseudo role of prison and state hospital, but without the legal sanction provided by a court of law. This places any facility in an untenable situation. If a resident refuses medication, do you restrict them? If so, you are violating their rights, and many will complain to IDPH. They have a right to refuse and are not children that can be grounded when they disobey. On the other hand, if you do not restrict them and they go out and something bad happens, the facility is then liable. If a resident, like Maratta, has a chronic drug or alcohol problem, should that resident be restricted? If you have a cousin that is an alcoholic, do you (or does anyone else) have the right to place them on restriction? Somerset cannot legally restrict everyone at risk of drug use. It is not a prison. And yet, if the facility does not and something happens, they are liable. This is a profound catch-22.
The state is, in essence, taking the very challenging problem of how to regulate the risk associated with severely and chronically mentally ill adults and dumping it on nursing homes. Within the law-enforcement and criminal justice system, the state could develop programs and systems for persons with mental-illness that become repeat offenders, programs in which the individual could be legally restricted and compelled to cooperate with treatment. Somerset did not contact Maratta’s parole officer. He was not even notified that she had been admitted to Somerset. But what was the parole officer’s responsibility? Upon the release of an inmate with the history of Maratta, wouldn’t the parole officer pro-actively be involved in where she was placed? While in the hospital, did the hospital social worker contact the parole officer to discuss her placement (if she was placed directly from incarceration, did the person arranging placement from jail not consult with the parole officer?) How is it that the parole officer relied solely on Somerset to be informed? If the criminal justice system were more responsible, then perhaps Maratta would have been placed in a secure, locked facility such as a state psychiatric hospital until she was deemed safe to re-enter the community. But she was not. Instead, she was sent to Somerset. And once there, the facility is held accountable for accomplishing what the law-enforcement, criminal justice and mental health system of Illinois could not: provide Maratta with effective treatment (with or without her cooperation) and keep her out of trouble. Of course they failed. And this sort of failure is widespread among IMDs and is entirely predictable. Fortunately, murder is a rare end-point.
Somerset is not without fault. If the IDPH report is accurate, the facility made several significant mistakes. The problem is that this kind of fault finding, which IDPH does well, provides a false accountability. It implies, ‘Had Somerset simply done what they were supposed to, none of this horrible business would have occurred.’ Such a perspective fails to recognize that rather than using the criminal justice and state mental health system to appropriately manage and treat high risk individuals, the state simply dumps them on nursing homes. The nursing homes, in turn, are expected to unofficially and quietly play the role of state hospital and prison as needed, but are inevitably doomed to fail, sooner or later. Why would one expect these facilities—without the legal authority or resources of the state— to accomplish what the state cannot?
Somerset could have refused to admit her. Somerset and all the other similar facilities could refuse to admit all potential residents like Maratta. But then, where will these people go? It’s a very good question. Does the state have an answer?