The teenager in custody was suicidal, which meant staffers at the Lincoln Village Juvenile Detention Center were tasked with near-constant surveillance.
Yet, for more than an hour, the observation check log lay untouched. It was 2:30 a.m. The staffer was asleep at the table in the control room.
In this 2012 case, the state worker denied the nap, saying he was just distracted -- even after a co-worker told him she saw him on the surveillance camera, asleep.
This was the staffer’s third suspension within 13 months, his fifth overall, for inadequate supervision of the youths in his charge. In another case, his lack of supervision allowed a resident to injure himself. And he eventually resigned amid his sixth internal investigation.
That type of misconduct isn’t rare in Kentucky’s juvenile justice facilities. Lack of supervision -- such as leaving residents unattended, skipping bed checks and falsifying logs -- is the most frequent complaint substantiated by the state’s Justice and Public Safety Cabinet’s internal investigations bureau, a review of records since 2010 shows.
Supervisory failures came under scrutiny earlier this year when 16-year-old Gynnya McMillen was found dead in her room at Lincoln Village. Investigators determined six staffers failed to do required bed checks and falsified logs, though officials said the employees’ mistakes didn’t contribute to the girl’s death. The coroner ruled Gynnya died in her sleep from a rare heart condition known as sudden cardiac arrhythmia. ( Read KyCIR's coverage of Gynnya McMillen's death)
The agency’s overall disciplinary numbers could signal a cultural problem within the facilities and a need for more training, said Ned Loughran, executive director of the Council of Juvenile Correctional Administrators.
Loughran, who spoke generally on juvenile corrections policy, said missing bed checks and falsifying logs should be considered a serious offense.
“Someone has to make sure policies are being followed,” said Loughran, who previously served as head of the Massachusetts Department of Youth Services. “It sounds like the culture is more for the convenience of the staff than the protection and safety of the youths.”
The Kentucky Department of Juvenile Justice operates 28 residential programs statewide, including detention centers, development centers and group homes that house about 380 youths.
Of 234 staff violations at DJJ facilities since 2010, more than half were for lack of supervision. About 29 percent of the complaints dealt with excessive or inappropriate use of force; other cases dealt with inappropriate or racist language, threats, sex or attendance issues.
Five people have been fired since 2010 for issues related to supervision. Three of those terminations were tied to Gynnya’s death in January.
LaDonna Koebel, acting commissioner of the Department of Juvenile Justice, said the department uses a “progressive discipline” approach to deal with staff offenses, for consistency and fairness -- although some incidents are troublesome enough to proceed straight to termination.
Until Gynnya’s death, Koebel said, nobody at the department realized the scope and severity of the supervision issue.
“You look at the big picture and you see areas that may warrant changes and approaches that the department hasn’t done before to address these situations,” Koebel said.
Koebel’s predecessor, Bob Hayter, was fired earlier this year in the wake of Gynnya’s detention center death.
DJJ was unable to provide information on how many employees resigned while under investigation, or how many employees were let go during a probationary period.
Among the disciplinary records reviewed by WFPL’s Kentucky Center for Investigative Reporting are numerous instances of staffers asleep on the job, falsifying records and a general indifference to the task at hand. In one instance, two residents were having sex while an employee rested in another room with his feet up. Other times, residents had to wake up staffers to get permission to use the bathroom, or were left unattended while employees stood outside talking or smoking.
One worker at Frankfort Group Home had been suspended four times before he was ultimately fired. The final straw? Surveillance cameras showed him entering a restroom with a blanket for two hours. The previous night, cameras caught him leaning back in a chair, his feet propped up on a desk, asleep.
In December 2011, an employee at Green River Youth Development Center earned a five-day suspension for repeatedly falling asleep. Not even co-workers could rouse him. He had already been awaiting discipline for the same offense months earlier.
At issue is more than just broken rules -- it’s about safety, said Michele Deitch, a corrections expert and senior lecturer at the University of Texas at Austin. She said bed checks and log books have a key purpose that goes far beyond a technical rule violation.
“When people are trapped in a cell, they have no ability to protect themselves,” Deitch said. “They rely on the staff as their source of protection.”
But an attorney for two of the staffers fired after Gynnya’s death said his clients are being unfairly singled out for a relatively common infraction.
In March, a Hardin grand jury indicted former Lincoln Village supervisors Reginald Windham and Victor Holt each on one charge of second-degree official misconduct. The pair, along with another staffer, Christopher Johnson,were fired for failing to properly check on Gynnya before she was found unresponsive in her room on the morning of Jan. 11.
No other staffers disciplined for inadequate supervision appear to have faced criminal charges in the last six years. A handful of cases involving force or sexual misconduct have led to criminal charges. Those internal investigations are the only ones automatically shared with local law enforcement, said Public Safety Cabinet spokesman Mike Wynn.
Neither the Hardin commonwealth’s attorney, who is prosecuting the case, or DJJ officials could recall another supervision offense turning into a court case. Both acknowledge the impetus was Gynnya’s death.
Hardin Commonwealth’s Attorney Shane Young said the case only landed on his desk because the investigation began as an inquiry into potential felony misconduct.
J. Clark Baird, the Louisville attorney representing both Windham and Holt, said his clients have never heard of anyone else being fired -- and definitely not indicted -- for a practice they allege is condoned.
Baird said the standard operating procedure was to backfill the logs if a check was missed, and is so routine there is a term for it: “catching up the checks.”
“The death of this young girl, which was tragic, just happened to shine some light on the facility and then for whatever reason, my clients were charged -- despite the fact that countless other workers at the facility, employees of the facility, did the exact same thing my clients are accused of doing,” Baird said.
Koebel, who served previously as the department’s assistant general counsel, said she isn’t aware of any evidence of this practice.
“We’re reviewing everything and really combing to find out if that’s been going on, because that would absolutely have to be corrected,” Koebel said.
She added that additional training and reforms are already underway at juvenile facilities in response to the issues Gynnya’s death exposed.
Staffers will be retrained across the state in the next few weeks on the importance of bed checks and maintaining accurate logs even if a bed check is missed, Koebel said. Meanwhile, officials are rewriting policies so that staffers get a verbal or non-verbal response from residents during waking hours, instead of assuming a resident is still sleeping.
Another policy that will be clarified: under no circumstances should a staffer eat a meal prepared for a resident, as one of the fired employees did after Gynnya didn’t respond to his offer for breakfast.
Reporters R.G. Dunlop and Alexandra Kanik contributed to this report. Kate Howard can be reached at khoward@kycir.org and (502) 814.6546.