Employees at a Tecumseh juvenile facility failed to properly supervise an 18-year old who died after a suicide attempt there, though she had been placed on suicide precautions several times before her death, a state oversight agency’s investigation has found.

The agency’s probe also found the teen was bullied by other residents and staff did not address residents’ grievances in a timely manner.

The Oklahoma Commission on Children and Youth released the findings in a 26-page report on Thursday. OCCY investigators listed 21 policy violations in the report, including for lack of staff training, improper supervision and failing to report incidents such as bullying and inappropriate sexual contact.

OCCY initiated the investigation into the Central Oklahoma Juvenile Center in January 2019 following the death of the 18-year-old woman, who was identified in the report only as “KF.” The teen died at a hospital on Jan. 8, 2019, seven days after she attempted to hang herself at the facility.

The Central Oklahoma Juvenile Center in Tecumseh, which is operated by the Oklahoma Office of Juvenile Affairs, is an 82-bed facility that houses youthful offenders and delinquents between the ages of 14 and 19.

The investigation stemmed from a complaint to OCCY that staff had failed to properly monitor the teen, and that a male employee had sexual relations with her and two other residents at the facility, the report stated.

OJA Executive Director Steven Buck said the violations have been “addressed through refinement of procedures, enhanced training, and personnel management decisions.”

“I am pleased with the progress COJC (Central Oklahoma Juvenile Center) is making in both care structure and staff training and preparedness,” Buck said in an emailed statement.

“Discovering ways for the Office of Juvenile Affairs (OJA) to improve our care of juveniles and procedures after this incident was a high priority to me, and I’m glad to see this was accomplished before my departure next month as OJA’s executive director.”

Buck, who announced his resignation from OJA last week, has said he is leaving to take a job as the president and executive director of Care Providers Oklahoma, which represents the interests of residents and workers in long-term care facilities.

OCCY’s investigation

Dorm residents found KF hanging in a bathroom at the Central Oklahoma Juvenile Center on Jan. 1, 2019.

OCCY’s investigators found staff had not checked on the teen, who had been in the shower, for more than 20 minutes before she was found, according to the report. A staff member said that although the facility had a 10-minute shower policy, it was rarely enforced.

One employee stated she had not been trained on the policies for resident showers, according to the report. Staff at the facility’s control center said they hadn’t received training on how to contact emergency services.

Two employees told OCCY investigators the teen had been “picked on” earlier that day and she “appeared to be sad on the evening of the incident,” the report stated.







A grievance made to the facility on behalf of KF on Jan. 6, 2019, stated “at least 3 residents continuously told (staff)… to check on resident KF and instead of physically checking on her (an employee) yelled and after getting no response she just sat back down and continued to talk about her relationship with her fellow co-workers,” OCCY’s report stated.

The grievance was logged as “received” two days after being filed but was not resolved within five days, as required by facility policy, according to the report. OCCY noted several grievances that were not closed in a timely manner, including three filed by KF.

The OJA Office of Public Integrity completed a criminal investigation into the allegations that employees left KF unsupervised in the restroom for an extended period of time, according to OCCY’s report.

The allegations of “unsatisfactory work performance, misconduct, neglect of duty, neglect, and caretaker misconduct,” by one employee was substantiated, the report stated. Allegations of unsatisfactory work performance, misconduct and neglect of duty by another employee were also confirmed.

Of the two employees, one resigned and the other was fired, according to the report.

OJA forwarded the findings to the Pottawatomie County district attorney, but no criminal charges were filed.

OCCY spoke with residents and staff members as part of the investigation, the report stated. Interviews indicated KF was often “picked on” by other residents.

The investigation found the facility allowed residents to attend co-ed movies, which allegedly caused some of the bullying incidents between women there, the report stated. When women were first placed at the facility in August 2018, OCCY had been told men and women would be kept separated at all times, according to the report.

Investigators reviewed logs that recorded when residents were placed on suicide precautions and found KF was placed on “severe” suicide precautions between Oct. 31, 2018, and Nov. 7, 2018, the report stated. She was again placed on severe precautions between Nov. 11, 2018, and Nov. 19, 2018.

In October 2018, the report stated, staff members found KF in her room with “pajama pants around her neck,” before employees placed her on suicide precautions.

The OJA Office of Public Integrity investigated reports of a male staff member having sexual relations with residents, but there was a lack of physical evidence, a lack of cooperation from other people allegedly involved and surveillance footage did not support the allegations, according to the report.

Other problems at the facility

Seven employees told OCCY investigators that “resident-on-resident and resident-on-staff assaults were commonplace at the facility,” according to the report. Staff members said they witnessed residents bullying one another and stated they saw contraband in the facility, such as joints, pills and cell phones.

Two residents said they didn’t always feel safe there.

One clinical employee told investigators there was no follow up from a behavioral health treatment specialist responsible for entering data for monthly treatment reviews, the report stated. OCCY investigators found five residents’ treatment plan reviews were incomplete from August 2018 to December 2018.

In the report, investigators noted several incidents when residents weren’t properly supervised.

In one case, investigators wrote, records indicated female residents had engaged in sexual contact on multiple occasions while a staff member looked on.

OJA disciplined that employee, according to the report.

An OJA Office of Public Integrity administrative investigation found two staff members performances were “unsatisfactory” for failure to properly monitor a suicidal resident and allowed her to harm herself in November 2018.

Another administrative investigation found the heating system on the women’s housing unit had been broken in December 2018 but youth were not moved to another unit for almost a week. The average was 44 degrees that week, investigators noted.

In OCCY’s report, OJA stated the unit’s dayroom had heat, and residents stayed there until they were relocated. The unit was repaired in January 2019, according to the report.

OJA response

In a response included in OCCY’s report, OJA stated it made steps to correct the violations.

To prevent contraband from entering the facility, OJA increased the number of security checks, staff, and relocated cameras to improve visibility, the response stated.

The agency noted that assaults had decreased dramatically over the last year after additional employees were placed throughout the facility, according to the response.

“For example for the month of November 2018 there were 87 Uses of Force, whereas, in March 2019 there were 14,” the response stated. “Staff assaults have also decreased drastically in the past months, for example in December 2018 there were 28 assaults on staff, whereas, there were four in March 2019.”

After KF’s death, OJA revised shower procedures, the response stated. The change requires two residents in the bathroom at one time with an employee in the room monitoring them.

The agency also addressed with staff that grievances must be resolved within three working days, according to OJA’s response.

“We have increased the level of accountability, and oversight to ensure grievances are resolved and in a timely manner,” the report stated. “We will continue to strive for excellence in this area.”

In response to the reported bullying, OJA stated “immediate response was taken.”

“There has been an increased emphasis placed in the ongoing process groups and psychoeducational groups,” the report stated.

OJA stated in its response that it put new leadership in place to address issues with the facility’s suicide prevention protocol.

“It is now the responsibility of the clinician who is assigned the resident who is placed on status to follow up daily,” the report stated.

In response to the violation that staff did not know how to contact emergency services, OJA said it has increased the number of “Code Blue” practice drills at the facility, which now requires staff to automatically call 911.

Construction has been underway at the Central Oklahoma Juvenile Center that will replace most of the existing buildings, which were not designed for juvenile justice use, said OJA spokesman Michael McNutt. The project, which was approved in 2017, aims to give the campus a more “therapeutic environment.”

“The campus will have improved sight lines for staff, which will improve supervision of residents,” McNutt said in an email. “The open dorm-style resident halls will be replaced with living areas featuring individual bedrooms with a window; increased natural lighting will add to the therapeutic environment.”