Newly released reports from the Illinois Department of Human Services' watchdog office reveal shocking instances of cruelty, abuse and poor care of patients who have mental illnesses and developmental disabilities at a state-run facility in rural southern Illinois.
The eight reports, obtained last month under the Illinois Freedom of Information Act, provide new evidence of an ongoing crisis at Choate Mental Health and Developmental Center, which has been the subject of numerous investigative articles by Lee Enterprises Midwest, Capitol News Illinois and ProPublica.
In one report from November, the IDHS inspector general wrote that two Choate employees who had broken a patient's arm in October 2017 bragged about how staff got away with abusing patients by providing scant details on reports and blaming resulting injuries on accidental patient falls. The staffers also boasted about intimidating and bullying other employees to keep them from reporting abuse and bragged that they retaliated against those who spoke up.
In another report, the inspector pointed to years of concerns about the care provided to patients who have pica, a disorder in which people feel compelled to swallow inedible objects such as coins and zippers.
Several nurses told an investigator that it was common practice to force patients with pica to dig through their own excrement with gloved hands or a spatula to determine whether objects they swallowed had passed, the inspector general found. The investigation was triggered by a complaint to the agency's abuse hotline made last spring by a facility monitor who observed a patient walk out of the bathroom with a bag of feces. Patients questioned by investigators said they felt disgusted by the practice and viewed it as punitive.
A clinical consultation conducted on behalf of the inspector general found that the practice violated nursing standards and amounted to incompetence on the part of the Choate nursing department. The facility was cited for neglect, though the inspector general did not cite individual nurses for misconduct because the investigation found it was a "widely accepted procedure." This week, an IDHS spokesperson told reporters that the practice was "limited to the reported incident and was stopped immediately upon discovery."
In yet another report, the inspector general cited two nurses for neglecting a terminally ill patient in the days before he died in July 2021. One of the nurses failed to properly manage his pain, and the other failed to notify a physician that the patient had lost 21 pounds in one week. These shortcomings caused him to experience pain, emotional distress and further deterioration of his physical health, according to the inspector general's clinical review. Proper care "could have provided him a higher quality of life and more time with his family," the report said.
These newly released reports, relating to events that occurred between 2017 and last spring, come on the heels of a series of news stories documenting repeated failures at the Choate facility. In September, reporters found that the IDHS inspector general had investigated more than 1,500 reported incidents of abuse and neglect over the decade ending in 2021, though staff have rarely faced serious consequences.
In addition to the abuse and neglect at the facility, which houses up to 270 people with disabilities, the series revealed a culture of cover-ups at Choate, later confirmed by inspector general reports. The news organizations uncovered workers colluding before being questioned by investigators, obstructing investigations and lying to avoid consequences in abuse and neglect cases. In response to that reporting, Gov. JB Pritzker said the patient abuse at Choate was "awful" and called for change.
IDHS has not disputed the news organizations' findings and has acknowledged the seriousness of concerns about the facility that date back years. Once again this week, in response to reporters' questions, the agency detailed some of the steps it has taken to correct poor conditions at Choate, including enhanced staff training on responding to abuse and neglect allegations, campus safety assessments and a partnership with an outside organization to provide additional clinical support for patients who have experienced trauma.
Other findings in the new inspector general reports include mental health technicians who neglected patients and compromised safety by sleeping on the job or failing in other ways to provide proper supervision. In one case from May 2019, two patients who had been left unsupervised each accused the other of rape. In another, a patient was discovered wandering naked outside at about 4 a.m. on a mid-December morning in 2021 when the temperature had dipped into the 30s. And in a third case, a staff member's failure to provide proper supervision led to one patient assaulting another in June 2022.
Further, an incident in November 2021 extended beyond neglect. A mental health technician was found to have also mentally abused and retaliated against a patient who wet himself after the tech rejected his request to use the bathroom. The worker made the man mop up the mess and tossed his personal letters in the bucket of dirty water, according to the inspector's report. When questioned by an investigator, one of the patients who witnessed the incident and corroborated the account began to cry and said he "was tired of being abused."
"Unwritten Rule" to Cover Up Abuse
A patient abuse case from 2017 reflected a broad range of problems that have been documented at Choate. It revealed how some employees hide abuse and obstruct investigations, retaliate against those who speak up and indoctrinate new employees into the cover-up culture. Their actions, the inspector general wrote in his November 2022 report, reflect "a brazenness and sense of impunity amongst certain Choate staff that must be combatted."
The case involved two mental health technicians who fractured a patient's shoulder in October 2017 but failed to report it. Nearly five months later, someone called the agency's abuse hotline and said they had overheard the technicians — Cody Barger and Jonathan Lingle — bragging about breaking a patient's arm and coordinating their stories to say the patient had fallen in the shower.
That call led the Illinois State Police to investigate. One person told them that he had been interested in working at Choate but had confided to Barger that he was not confident he could handle the residents. He said Barger told him it was easy "to get around stuff," for instance by claiming the patients had injured themselves.
Another worker told police that Lingle had instructed him to disregard most of what he would learn in training, saying that he should fill out injury reports with minimal details and abide by the "unwritten rule" that staff cover for each other.
But in this case, the staff culture of complicity went even further. Months later, a security officer at the facility told Barger who had called in the complaint against him. Two days after that, he showed up at his then-fiancee's house, yelling at her for reporting him, knocking her down and daring her to kill herself before shooting an AR-15-style rifle twice into the air, according to police records. The woman's young son called 911. The security officer who disclosed the identity of the person who reported Barger to the inspector general's office was initially charged with felony official misconduct, but her case was dismissed; she received more than $65,000 in back pay.
Barger and Lingle were fired from Choate in 2018 for unrelated misconduct. Both men were criminally charged in the injury case, not with battery, but with obstruction. They each pleaded guilty and received probation. Both men agreed not to seek employment in a health care setting. In the administrative review, the inspector general ruled that claims that both men had physically abused the patient were substantiated. Attempts to reach Barger and Lingle by phone, via Facebook messages and through their attorneys were not successful.
The case prompted Peter Neumer, the IDHS inspector general, to issue recommendations to combat Choate's "cover-up culture," including subjecting employees to consequences for retaliatory threats or behavior. He also reiterated his repeated request for Choate to install cameras.
The IDHS spokesperson said the agency protects employees who report misconduct, and that "instances of retaliatory threats or behavior are investigated and administrative actions taken as appropriate." She said that IDHS is in the process of installing cameras at outdoor locations across the campus and in some interior public spaces.
More broadly, the troubles at Choate have led to calls for reform from advocacy organizations, the IDHS inspector general and the governor. Last month, Pritzker renewed demands that Choate clean up its act or face closure.
"We obviously want to make sure that we're keeping everybody safe in these facilities," Pritzker said at an unrelated news conference in January. "And if we can't — and I've said this before — then we shouldn't have that facility open."
Stacey Aschemann, a vice president with Equip for Equality, a legal advocacy organization that has been appointed to monitor troubled state facilities including Choate, said the most recent reports of misconduct were "very disturbing and at times chilling to read." Staffers' actions, she said, were inhumane, set individuals back in their treatment and, in some cases, caused lasting harm.
"The large number of staff involved in these multiple substantiated OIG reports reveals a concerning trend indicative of a culture problem at the facility," she said.