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Maryland health regulators say they found serious violations at the group home for disabled foster children where a 10-year-old Baltimore boy died in July — including conflicting records on his care, and miscommunication between staff and the emergency responders and medical personnel who labored to save him — but nothing that contributed to his death.

That conclusion, issued more than four months after the death of Damaud Martin at the Laurel-area group home, surprised child advocates. They call the failure of investigators to interview the nurse who cared for the boy on the night he died a major flaw.

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The nurse told The Baltimore Sun in July that the group home, which was managed by a state contractor called LifeLine, was not properly staffed — a violation that state inspectors had found weeks earlier.

"An investigation that fails to interview an involved staff member is incomplete, and its findings are questionable," said Nancy Pineles, managing attorney for the Maryland Disability Law Center.

"To perform an investigation of any incident, particularly a serious incident such as a death," Pineles said, "the investigator must make every effort to interview the staff who were directly involved, including all staff who were on duty and possibly staff who were not on duty but may have information about care in the home."

Damaud had been in a coma-like condition since 2008, when he suffered trauma that doctors described as the equivalent of shaken-baby syndrome. After his death July 2, Gov. Martin O'Malley promised a thorough investigation, and his Cabinet officials promised to reform oversight of group home contractors. But investigators say they were unable to interview the nurse.

The Baltimore Sun phoned the nurse, Mary Zelio, on Thursday, using the number listed in the Anne Arundel County police report about Damaud's death. She said no one from the state had tried to interview her.

There is no indication that two other nurses working the night of Damaud's death were interviewed.

Maryland Health Secretary Dr. Joshua M. Sharfstein told state lawmakers in a letter that investigators "did not find evidence that the services provided by [LifeLine] contributed to the death."

The state medical examiner ruled the death a homicide and said it was caused by complications from head trauma Damaud suffered when he was abused in 2008.

Sharfstein said inspectors were not able to make a determination on staffing based on the evidence to which they had access before their investigation was completed on July 7, five days after Damaud's death. Investigators based their findings on nursing notes, the 911 recording, police and autopsy reports, staff records and interviews.

"The regulators make the findings that they have evidence for," Sharfstein said. "The absence of a finding is not the same as if they found no problem."

The "mortality investigation" found mismanagement with the boy's care — including conflicting orders to save him and to let him die if he suffered a life-threatening condition such as cardiac arrest.

On the night of Damaud's death, LifeLine staff "failed" to provide "all relevant information" about the boy's "medical status during a medical emergency," the investigators found. Staff also provided the wrong address to a 911 operator and wrote in notes that the emergency number was called 25 minutes earlier than was recorded. In addition, the nurse on duty failed to inform a 911 operator that another nurse had already begun to perform CPR on the boy.

Investigators also found that months earlier — in "the winter of 2014" — Damaud had been hospitalized for seven days. They cited LifeLine for violating state regulations because no one from the company could be reached to provide hospital doctors with essential medical information, including current medications and ventilator settings.

LifeLine staff "did not communicate with the hospital regarding [Damaud] until the sixth day of [his] hospitalization," the investigators wrote.

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State officials say they could not determine the staff-to-resident ratio at the group home on July 2. There were 10 children living at the LifeLine apartments. Regulators were in the process of relocating the children after LifeLine chief executive Theresa Martin informed the state she was closing the company because of what she characterized as inadequate state funding. Martin could not be reached for comment.

Her decision came shortly after regulators told her they were going to revoke LifeLine's state license to care for disabled foster children. They made that decision after inspectors cited LifeLine in late May for what they found was a failure to provide sufficient staff to protect the "health and safety" of all of its children.

They also cited the firm for providing what they said was inadequate care to a 19-year-old resident who had to be hospitalized for an infection that spread from a gaping bed sore on his buttocks into his bones. Their investigation was spurred by complaints from the guardian and physical therapist of the 19-year-old.

The police report on Damaud's death indicates there were three nurses on duty with a supervisor on call — although the supervisor did not answer his phone when Zelio called him for help, the police report states. Zelio told The Sun that the care plans for each child called for one-on-one supervision and that she and other staff had been complaining for months about being understaffed.

Advocates for foster children questioned the findings of the report, and the fact that investigators placed so little blame on LifeLine.

"It's not like the report says that everything that LifeLine did was according to regulation and he just died anyway," said Joan Little, chief attorney for the Maryland Legal Aid Bureau's Baltimore child advocacy unit.

Melissa Rock, child welfare director for Advocates for Children and Youth, noted that several deficiencies in Damaud's care were flagged by investigators.

"The deficiencies do seem directly related to Damaud Martin's medical condition and care," she said.

The state medical examiner said Damaud's death was caused by "complications from cerebral palsy due to [the] head trauma" he suffered in 2008.

The full autopsy will not be available until Baltimore law enforcement officials complete their investigation.

Damaud's mother, charged with child abuse, entered an Alford plea in 2009. The plea means she did not admit guilt, but acknowledged prosecutors had enough evidence to convict her. She has denied hurting Damaud.

The state has relied on four contractors to provide services to medically fragile foster children. Last year the state awarded $35 million in contracts to LifeLine, Second Family and two small operators to provide 62 beds with around-the-clock nursing care.

A Baltimore Sun investigation of LifeLine this year found that the firm continued to win contracts from the Department of Human Resources despite several problems at its Anne Arundel County operations.

The problems included deficiencies in medical care, a founder imprisoned for arson, unpaid taxes, a bankruptcy filing, office lease problems and police reports of abuse and neglect unknown to regulators.

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A separate Sun investigation of Second Family, the state's largest provider of such services, found that it had its own administrative and care problems. Those included neglect and abuse incidents that led to three employees being fired this year. Two of those employees had hit and kicked a mute autistic child, state inspectors found.

State health and social services officials are continuing to evaluate ways to improve regulation of group homes for disabled children. Those actions began after Sharfstein and Human Resources Secretary Ted Dallas gave a public briefing to two dozen lawmakers in July on LifeLine and the oversight of group homes for disabled individuals.

The state health department sent letters to nearly 300 contractors in August to remind them of their obligation to report incidents that involve police, fire or medical assistance.

Sharfstein's agency last month showed lawmakers a five-step plan to reform oversight by improving coordination among the agencies that supervise group homes, increasing scrutiny of contractors' finances and appointing an employee to implement and oversee the enhancements.

Sharfstein also established a task force that includes advocates and others to study oversight and present further suggestions by January. The task force is scheduled to meet Wednesday, and again in December and January.

In addition, Dallas created a new "financial incident form" to help his agency improve "monitoring of the financial condition of group homes and foster care providers for children in Maryland," he wrote in a letter to lawmakers last month.

He said the eight-question form is designed to alert regulators when financial conditions arise that "could potentially affect" medical care. If providers answer "yes" to any of the questions about bankruptcy filings, tax liens, unpaid taxes, insurance policy cancellations, late leases or rent payments, plans must be made for corrective action.

The department sent the forms to 112 providers across the state in September. Six reported such concerns, Dallas reported, but only one — a child placement agency — was unable to resolve its problems. The state has canceled its contract, Dallas said.

Health officials say they are continuing to assess services so they can advise lawmakers on potential legislation to strengthen oversight.

A report on Second Family is expected next week.

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