Mellissa Ryan, an employee at South County Habilitation Center, helps Tom Dwyer (seated left blue hat) and Robert Potter (seated right red hat) play tic-tac-toe in their unit at the Wednesday. (ODELL MITCHELL JR./P-D)

They are expected to work in dangerous environments, with challenging people, and often with little training.

And, in doing all that, the thousands of people who care for the state's mentally retarded and mentally ill residents must cope with one more issue: Pay that barely beats wages offered by fast-food restaurants.

It's a reality often cited by state officials, academic experts, advocates and workers themselves in explaining why it's difficult to eliminate abuse and neglect of residents, and it's a reality that the state has failed to adequately address.

A Post-Dispatch investigation found that:



Caregivers are paid about $9 an hour - making it hard to keep, recruit and train workers on how to handle challenging situations that can quickly evolve into abuse or neglect.

Caregivers have been injured by patients at rates far higher than even prison guards, further hurting recruitment and creating an environment that could spark mistreatment of residents.

The state has paid consultants to devise ways to lessen abuse and neglect, but the state failed to apply them systemwide.

Across the state, there are thousands of workers who provide quality care to mentally retarded and mentally ill residents. Parents offer story after story of caregivers who go beyond the job requirements, holding birthday parties or taking residents on shopping trips or out to eat.

But state officials and private facility operators acknowledge that the poor working conditions make it easier for bad workers - and some good ones - to mistreat the people they're supposed to be protecting.

The Mental Health Commission, which oversees Mental Health's management, noted in a joint statement this month that it's "abundantly clear" that workers "desperately need higher levels of support, leadership, and continuing education in order to function in their vital role."

To Scott Shepherd, fixing the problem requires a change of culture.

Shepherd, who has a mentally retarded son, said he began a suburban Kansas City company eight years ago to staff private facilities. He told the commission this spring that it's not enough for a majority of workers to provide good care.

"The thing that scares me is that we are only as safe as our worst employee," he said. "We're that close."

Continuing struggle to train and retrain

To get a job caring for people who may have multiple and severe disabilities or conditions, candidates need a high school diploma or its equivalent. The state runs criminal background checks through the Missouri Highway Patrol for felony convictions, which disqualify people as caregivers. But the Highway Patrol records do not include misdemeanors - even violent ones.

Once hired, new employees get two weeks of training and then spend a week watching other aides do their jobs. The training includes 16 hours learning how to manage aggressive residents and four hours on how to prevent neglect and abuse.

The private sector has fewer training requirements. Caregivers who work in both public and private facilities say the training is less extensive in private homes, particularly specialized care for some of the most challenging residents.

They receive training in abuse and neglect, emergency drills, and how to speak to residents and their families. They also must be certified in CPR.

But sometimes they don't keep current with their certification - a problem cited in a death in a Kansas City group home in 2001.

A worker at the Nova Center gave a 12-year-old autistic boy a doughnut. Moments later he began coughing and turning blue.

The worker tried to use the Heimlich maneuver to dislodge the doughnut, then started CPR. The worker's certification had expired, according to the Mental Health Department finding.

The worker was the only person on duty. Before paramedics arrived, the boy had stopped breathing. By the time he got to the hospital, the boy was dead.

After investigating the boy's death, the state ordered the center to make sure all workers were current on their CPR, first aid and other training.

'A pittance of pay'

Mental health officials acknowledge the need to boost training. The department is working with the University of Missouri at Kansas City on a pilot program to train workers over the Internet. It's part of a push to make working as a direct-care aide seem less like a dead-end job and more like a career.

Still, state officials, advocates and researchers acknowledge one of the best ways to make the job seem more like a career is simple: Pay more.

The average pay is $19,000 a year. And that's for a worker in a state facility. Those in private facilities commonly make less money, with fewer health benefits.

"We expect them to do it for a pittance of pay," said Bill Edmonds, the retired superintendent of a state-run facility in Nevada, Mo. "I had people working for me on food stamps, and that's a shame that people doing that kind of work have to rely on public assistance."

A 2004 study by The Associated Press found the Department of Mental Health had the highest number of workers who qualified for welfare benefits of any state agency in Missouri.

The lower pay makes it harder to hire people, said Felix Vincenz, who in February was named the head of all 19 state-run facilities.

"I think too often we've been in the mode of 'Let's take whoever comes across' because it's so challenging to get folks on board on some of these low-level positions," Vincenz told the commission this spring.

Some caregivers must work other full-time jobs to make ends meet. And then there's the forced overtime in state centers, some of which are so short-staffed they require workers to do two double-shifts a week.

Joe Lawrence, spokesman for the state workers' union, the American Federation of State, County and Municipal Employees, blamed state officials.

"When you have the worst-in-the-nation state-employee pay, on top of chronic understaffing and chronic overtime, they are fueling the turnover," Lawrence said. "This will leave staff vulnerable."

Researchers say low pay is a problem across the country. In Missouri, there's little debate from Department of Mental Health officials, who say they wish they could pay more.

In four years, the department's General Revenue funding was sliced by a tenth - resulting in cuts to the state workforce of 16 percent. This year, the Legislature gave back nearly all of the shortfall.

The new money will pay for more workers and a 4 percent raise for state workers - about $760 a year more for the average worker. The Legislature also approved a 7 percent boost in the amount paid to private facilities for each resident, but it is up to the providers how much of that will go to workers.

A violent workplace

State employees will get a little more money, but they still are walking into dangerous workplaces.

Police reports and state records show they have been hit, slapped, punched and stomped on by the patients they care for.

They've suffered black eyes, shattered teeth and broken noses, ribs, jaws, shoulders, cheeks and eye sockets.

Prisons may look more dangerous with their razor wire and high security but state workers compensation data shows that it's far more dangerous to work in a state facility caring for mentally retarded or mentally ill residents.

Workers who care directly for mentally retarded residents are four times as likely to be hurt by a resident as a prison guard is to be hurt by an inmate, according to a Post-Dispatch analysis of state injury data.

For workers who care for the mentally ill, the rate is nearly three times as high, the analysis showed.

At least 135 times since 2000, workers have filed police reports, complaining about such things as residents pummeling them, choking them unconscious and throwing urine on them.

State data shows the most abuse of workers occurs in the psychiatric hospital in Fulton, which houses some of the state's most dangerous mentally ill criminals.

In the state's 2004 fiscal year, Fulton workers suffered 331 injuries at the hands of patients. That is more injuries than prison guards suffered that year at the hands of inmates in the entire state correctional system.

State workers and officials offer a slew of reasons for the violence against workers across the system - chronically short-staffed facilities, frustrated patients who lack the mental capacity to control their anger, and caregivers who lack the proper training to calm those patients.

Department of Mental Health Director Dorn Schuffman said that prison guards must only ensure inmates don't escape or hurt each other, and they often do it from behind protective barriers. Mental health workers must be "therapeutically engaged" with residents, and deal much more passively with residents who turn violent.

Last year, the state began a pilot program at Fulton to teach workers safer ways to restrain violent residents. They hope to get federal money to expand it to workers across the state.

"A lot of these situations occur where our staff doesn't feel safe and may adapt ways (to cope) that are inappropriate," Vincenz told the commission.

'Not a pleasant place'

In the meantime, the level of violence has spread fear among some workers. That's particularly true at Fulton, said Kevin Morris, who has repaired equipment there for eight years.

Each morning Morris drives into the center parking lot and walks through electronic gates that clank shut behind him. Once inside, he said, there is no protection from violent patients. This spring, he watched a patient grab an aide by the neck and beat him so hard the aide's glasses flew off and his ear began to bleed.

"You are really taking your life into your own hands just to get the job done," Morris said. "You have to always be looking behind you. It's not a pleasant place."

Recent research suggests the violence may have a chilling side effect: Fueling abuse and neglect of patients throughout the system.

A 2005 study found that adolescents in one Chicago neighborhood who witnessed life-threatening gun violence were more than two times as likely to commit gun violence within two years as peers of similar backgrounds who didn't witness it.

Harvard University psychiatrist Felton J. Earls, co-author of the study, said the same findings probably would hold true in centers for cognitively disabled people.

"In our case, the environments were neighborhoods," Earls said in an e-mail from a research location in Tanzania. "The workplace produces closer encounters than neighborhoods, so it should be true" inside the centers as well.

The logic makes sense to Joan Laramie.

Laramie spent four years caring for mentally retarded residents at the Bellefontaine Habilitation Center in Bellefontaine Neighbors, and she said that she often saw workers strike back at residents who tried to hurt them. Those workers, she said, did not take into account the residents' disabilities that led them to be violent.

"When a resident would do something to hurt a worker, I would hear the worker say, 'I'm gonna get you back,'" she said. "The worker would try to show the residents that, 'Hey. I'm the boss.'"

Management missteps

Mental Health officials have never studied the correlation between the abuse of workers and residents, but they acknowledge they've long been aware of the other issues - and haven't done enough to address them.

After a mentally retarded resident died in 2004 from neglect at the state-run Bellefontaine Habilitation Center, officials conceded that mistreatment was so out-of-control that they needed to hire a private consulting firm to fix the center.

The consultants found key deficiencies in staffing levels and interactions with residents, but agency officials never implemented them in similar centers, such as Northwest Habilitation Center near Overland.

In the past seven months, workers' actions at Northwest were blamed on two deaths of residents, which led to an unprecedented investigation of abuse and neglect by the commission. The commission on Tuesday named one of its own members, Ron Dittemore, to temporarily lead the department while it searches for a permanent replacement for Schuffman, who retires July 1. The commission said the new director will have an "enhanced set of expectations" in keeping residents safe.

Schuffman told the commission in April that years of budget cuts resulted in a bureaucratic culture that adopted the mantra of simply "making do."

"And that's part of when bad becomes normal," he said. "Urgency is a key issue ... and I think it has been wholly lacking."