Late one June night, after taking the garbage to the trash bin, as he often liked to do, a young man living at a home for people with disabilities in Clinton missed his family and decided to start walking home.
The 22-year-old, who lives with autism among other disabilities, had wandered away at least six other times in the past two weeks. But with the facility engulfed in a rash of COVID-19 cases, the two staff members at the Whitten Center assigned to his unit didn't know that. They were looking after 14 people, far more than they should have been.
In fact, they didn't notice his absence at all until 45 minutes later, when police called to inform them the young man had been hit by a car and was recovering at the local hospital.
The S.C. Department of Disabilities and Special Needs, which runs the Whitten Center and seven other sites like it across the state, says COVID-19 outbreaks have been hard to prevent. Already strapped for staff, the coronavirus pandemic has worsened an understaffing problem and, at times, caused dangerous conditions for both staff and residents.
The total cases at the Laurens County space — 230 in staff and residents as of Friday morning — is higher than the raw numbers at any nursing home or assisted living unit in South Carolina since the pandemic began, according to S.C. Department of Health and Environmental Control data.
The state disabilities agency maintains they followed protocol. Regulators disagreed, and over the summer even threatened to withdraw federal funding, according to state and federal records obtained by The Post and Courier.
As COVID-19 sweeps through nursing homes and other centers that care for people for a long time, disability advocates say South Carolina lacks a roadmap to do what would keep people safest: Move them out.
South Carolina is one of only a handful of states that doesn't have a plan to move people out of group settings 20 years after the landmark U.S. Supreme Court Olmstead decision resolved that unnecessary institutionalization violates people's civil rights.
Understaffing leads to critical problems
Situated in a small town between Greenville and Columbia, the Whitten Center is home to people with some of the most severe disabilities. The 100-year-old operation struggles to find staff up for the task of caring for them. At times, people unsuited to the work have landed jobs there.
In an incident last year, a staff member struck a resident across the face, which resulted in criminal charges from the State Law Enforcement Division. On another occasion in March, an employee held a resident's arm and plugged their nose while administering medication. And in April, one employee hit another with a chair; the assaulted employee went home and called police.
The employees responsible in those incidents were fired.
But that didn't solve the staffing issues, and COVID-19 hadn't arrived yet.
As was the case across the state, the coronavirus was quickly spreading in Laurens County and the rest of the Upstate in early July.
On June 26, Whitten administrator Randy Davis sent a letter to staff and families of residents. He wrote it is "possible to overcome these challenges" and said "our agency has taken proactive measures to respond to COVID-19." He also chided staff members for sharing about the outbreak on their social media pages.
"This is harmful, and serves no positive purpose," Davis wrote. The department did institute a $3-per-hour pay raise for staff who worked with COVID-19 patients. At that time, 17 people in Whitten's care were positive.
By June 29, the day one resident was hit by a car, there were 140 cases among staff and residents, and understaffing problems boiled over. One employee told regulators they “did not feel there was enough staff to provide for the safety of the clients" that day, and they felt "staff and clients were put in a dangerous situation."
But the outbreak wasn't done. By the time July was over, 30 percent of residents and 40 percent of staff had gotten sick. A spokeswoman for the state disabilities agency pointed out that despite the high rate of illness, the mortality rate within the space was low. Eight residents and three staff members have died.
That said, investigators with the state and federal health departments found the operation failed to follow some COVID-19 guidelines. There were gaps in health checklists. Staff members came to work when they were feeling sick, exposing people around them. Inspectors noted one person was moved out of their room when they caught COVID-19, but their soiled bedsheets and belongings were left behind, posing a risk to a roommate.
Residents were kept together even after someone tested positive for the virus. Disinfectant ran short, and employees were told to share protective gear when they shouldn't have.
"Some staff have worked 24 hours and still have to be back for the next shift," an unidentified person warned investigators. "The workers are exhausted and worried about quality of care between resident ratios and lack of rest.”
Inspectors found in a walk-through in early July "there is no backup plan" when staffing levels at the center fall too low. Promises the facility made to fix the problem were at first deemed insufficient by the Centers for Medicare and Medicaid Services, which threatened to stop reimbursing the Whitten Center unless more substantive changes were made.
The Whitten Center was able to assure regulators they would improve workforce shortages.
Staff also alleged — in a TV news report and in complaints to investigators — that protective gear was kept locked away from people who needed it even as the virus ran rampant. The state agency disputes that fact, with leaders at the agency saying employees were given the appropriate gear when the time was right, and inspectors found no evidence the allegations were true.
In an interview, associate state director Rufus Britt pointed out inspections at the agency's other facilities this year came back with clean reports. Britt said the agency has learned to deal with the virus as months have gone by. And he maintained the agency did the best it could with the resources available.
South Carolina's disability rights advocates say it would have been better if people weren't grouped in arrangements like the Whitten Center at all.
A possible solution
In October, disability and legal advocacy groups called on Gov. Henry McMaster to move people out of institutions like nursing homes and the Whitten Center as quickly as possible, given the rapid spread of COVID-19.
Anna Maria Conner, an attorney with Protection & Advocacy for People with Disabilities, said many people with disabilities have medical conditions that make them vulnerable to the virus.
"One way to protect these people is to reduce the population in these care facilities," Conner said. "You do that by moving people into less restrictive settings."
The 1999 Olmstead decision found it violates people's civil rights to keep them in institutions if they could live with support in their communities. The decision also called upon states to develop a roadmap laying out how that change could happen. Across the country, state mental hospitals and other large institutions started to close, pushed along by government lawsuits.
But 20 years later and long after the majority of states have complied, South Carolina is one of fewer than five states that lack any kind of Olmstead Plan and isn't working to create one, according to a Post and Courier review.
So, Conner said, her organization along with the ACLU, AARP and a coalition of others are pushing South Carolina's government to develop a plan.
Some states, like Florida, have a set of policies spread across agencies. Michigan has a similar piecemeal, but it also phased out any facilities like the Whitten Center, a spokesman for Disability Rights Michigan said.
Sarah Nichols, director of public relations at Able South Carolina, said COVID-19 put a spotlight on the urgent need to create a plan. But the imperative for one was evident long before 2020.
"This is something that's kind of been brewing for a long time," Nichols said. "South Carolina has really failed in this regard to provide this plan and these services to people in the state."
Nichols added developing an Olmstead Plan could be done at zero cost to the state.
Lawsuits by the U.S. Department of Justice, meanwhile, can be costly. Though South Carolina has so far escaped a lawsuit from the Justice Department, other states without a plan have been the targets of drawn-out legal battles. Government lawyers launched an investigation into North Carolina's mental health services in 2010, for example, culminating in a settlement in 2012 that required the state to overhaul its system. Now, North Carolina is creating an Olmstead Plan.
Not having a plan doesn't violate the federal law, but having one gives states a bolstered legal argument that they have taken steps to support people with disabilities living in their communities.
Britt said moving people out of group settings "is naturally part of our mission." People in the system are constantly evaluated to determine whether they can be moved.
Asked whether anything could have been differently to prevent the outbreak, Britt said the agency's focus is on education of its workforce and hiring.
During a commission meeting in mid-July, agency director Mary Poole said of COVID-19, "it’s something that all congregate care settings who rely on staff to provide close-proximity care are going to face."
That is certainly true at the S.C. Department of Disabilities and Special Needs, where four of its six large sites have active COVID-19 outbreaks — including at the Whitten Center.