On the night that 10-year-old Damaud Martin died at a troubled group home in Anne Arundel County, there were not enough staffers to handle the care specified for its severely disabled residents, according to the nurse on duty at the time.
Mary Zelio, who was watching over Damaud and two other residents, said Friday that each of their care plans called for the home's operator, LifeLine Inc., to provide one-on-one nursing. But she was the only LifeLine nurse on duty in the apartment, one of four the state contractor has used for its group home for disabled foster children.
"It was understaffed," said Zelio, who has worked for LifeLine for two years and was caring for children who suffered from paralysis and were breathing through tracheostomy tubes. "I complained all the time. Everyone has been complaining. They'd just say, 'We know, we know, we'll fix it.' "
LifeLine has been cited by state regulators for such problems. Regulators told the Laurel company a month ago that its license was going to be revoked after they found that "staffing patterns addressing the health and safety needs of each child had not been maintained" among other problems, records show.
The company's staffing patterns will be reviewed as part of the state investigations into Damaud's death, "but it would be premature to comment until the investigations are completed," Patrick Dooley, chief of staff for Maryland Health Secretary Dr. Joshua M. Sharfstein, said in an email.
LifeLine did not respond to a request for comment. The company's chief executive said in a June 5 letter to regulators that state funding was not adequate to cover the costs involved in caring for the children and volunteered to surrender its license.
The state has moved a dozen children from the company's care, with the moves being completed July 3, the day after Damaud died.
Child advocates said Friday that the state should have done more to make sure children at LifeLine were receiving proper care over the past four weeks rather than determining where to move them.
Nancy Pineles, managing attorney for the Maryland Disability Law Center, said the state fails to follow up on such staffing concerns.
"The staffing ratios are set to protect the children," Pineles said. "All along the line there were failures to monitor this agency adequately to ensure the safety of the children. That's very troubling to me."
Maryland's secretary of human resources, Ted Dallas, said his agency worked with LifeLine and health officials to move the children safely over the past month. He said several children were removed from the apartments before Damaud's death July 2 and that seven others were moved afterward.
The boy required around-the-clock care. Prosecutors said his mother had shaken him so hard in 2008 that he was left in a coma-like state. Tamekia Martin was convicted in 2009 of first-degree child abuse and received a 15-year sentence, with most of the prison time suspended.
Baltimore police have taken over as lead investigators in the current case because of the possibility that an autopsy could list homicide as the cause of death, said Detective Sgt. Jarron L. Jackson, a police spokesman. If the autopsy finds that the boy died as a result of the injuries sustained in 2008, his mother could face additional charges.
An autopsy could take "a while," said Bruce Goldfarb, a spokesman for the office of the chief medical examiner. The office needs to request and review police and medical records and perform lab tests, he said.
Tamekia Martin could not be reached for comment Friday.
She told The Baltimore Sun in 2008 that she did not hurt her son, who had been removed from her custody in 2006 after an allegation of abuse but was returned to her care the next year. She said the injuries in 2008 resulted when he fell off a bike and hit his head and later that day fell down a flight of stairs.
The Baltimore Department of Social Services became the boy's legal guardian, and he was placed at LifeLine on Dec. 4, 2013, according to an Anne Arundel County police report.
According to county police, paramedics arrived at LifeLine's apartments in the Russett Green community in the Laurel area about 4:30 a.m. July 2 and found Damaud in cardiac arrest and a nurse performing CPR. An hour later, a Howard County doctor advising the CPR by phone declared Damaud dead.
Zelio said her shift began at 11 p.m. July 1. Managing three children with significant needs requires constant vigilance, such as cleaning a tracheostomy tube at the same time an alarm is going off indicating that another client's tube also needs to be cleared, she said.
That night, Damaud had been given a suppository, she said. By 3:45 a.m. the boy still had not had a bowel movement, according to the police report.
Zelio tried to call her supervisor by phone about Damaud but was unable to reach him, the report states. Another nurse from a separate LifeLine apartment in the same complex arrived while Zelio called paramedics.
LifeLine has run into problems with state regulators in recent years. In 2012, the state revoked the company's license to care for disabled adults. The revocation came after two residents died at an Owings Mills facility, and the state cited the company for violating standards of care.
State officials allowed the company to continue providing care to disabled foster children, saying they had not found similar problems with that program.
In September 2013, the state awarded LifeLine a $4.9 million contract to provide services to 13 "medically fragile" children. The company received nearly $11,000 per month for each child's care.
Joan Little, chief attorney for the Maryland Legal Aid Bureau's child advocacy unit, said the state is obligated to make sure it is paying for a high standard of care for medically fragile foster children who suffer from conditions such as cerebral palsy, blindness and paralysis.
"There aren't that many children in these circumstances, but for those who are, the state has an obligation to provide a level of service that they need," she said. "It's appalling to me that children were living under these circumstances. It really cries out for the need to provide some other way to monitor places like this."
Little added, "Maryland is not a poor state. It can afford to provide quality service to a handful of foster children who have high-end special needs"
Little said the state should have sent in more nurses once it found that staffing levels at LifeLine were inadequate. She said moving the children quickly isn't always the best solution because many foster children have grown accustomed to their schools and their families have adjusted to visiting them in Laurel.
Baltimore Sun reporters Justin George and Erin Cox contributed to this article.