LINCOLN — Twice, security footage showed a teenage girl falling to the ground and suffering multiple seizures, while lights flashed from fire alarms and water poured from a broken sprinkler head.
The footage showed other youths — fellow residents at Nebraska’s now-closed center for female juvenile offenders in Geneva — go check on the girl, help her to a quieter area and try to shield her from the chaos.
It also revealed multiple staff members ignoring the girl’s distress and even, at one point, apparently telling the other teens to step away from her.
Nebraska’s state ombudsman and the inspector general of Nebraska Child Welfare described the August 2019 incidents in a new investigative report that looked into what caused the deterioration of the Youth Rehabilitation and Treatment Center in Geneva.
The report, released Tuesday, pointed to failures of leadership on multiple levels and multiple fronts, in ways that compounded the consequences of each.
“Our investigation made it clear that this was not a crisis that arose as the result of any one person or single incident, but rather resulted from failures in the systems and leadership of the state,” said Julie Rogers, the state ombudsman. “These failures had a profound effect on the youth the (center was) meant to serve.”
She said the Department of Health and Human Services, which runs the state’s juvenile offender institutions, “faltered on their legal responsibility to keep the girls in a safe place for treatment and rehabilitation.”
HHS officials removed all the female offenders from the Geneva center in August 2019, after staff shortages, inadequate programming and deteriorating buildings combined to make the facility unlivable. The girls were moved to the formerly male-only juvenile offender center in Kearney.
According to the new report, the crisis developed because:
Key positions at the Geneva center were left vacant or were not staffed appropriately between 2015 and August 2019. Among the positions affected were the center administrator, facility operating officer, clinical psychologist and program director and the person in charge of training. At several points in time, managers were assigned to duties at multiple facilities in different locations with different missions.
There was a lack of staff and lack of training for staff. The problems included pulling staff from other HHS institutions, who reported being thrown into the job without training and feeling unsafe. Even so, Geneva staff was required to put in “an enormous amount” of mandatory overtime hours.
There was a failure to provide programming and treatment for the youthful offenders, especially as staff became stretched thinner and key supervisory positions remained unfilled. Without meaningful activity, the girls’ behavior worsened. Some caused damage to the buildings, which went unrepaired until the facility became unlivable.
“The lack of programming and treatment combined with, and exacerbated by, the lack of staffing and the absence of key positions proved to be a devastating combination,” the report said.
The HHS-run juvenile offender facilities serve youngsters ages 14 through 18 who are sent there by the courts for breaking the law. The numbers of youth sent to the centers have dropped as new state laws limited judges to sending only youths who have already been through less-restrictive treatment.
The new report said 94% of the girls at the Geneva facility in August 2019 had a history of being abused, neglected and assaulted. All had been diagnosed with a behavioral disorder, a mental health disorder or both. Many had been through a long series of out-of-home placements.
Over the summer, HHS officials announced plans to transfer the female offenders from Kearney to a former Hastings Regional Center building. A new state law bars the girls from being moved until March 30, the deadline for the state to submit a strategic plan on how to deal with troubled youths. The department also has opened a new facility in Lincoln for male and female offenders needing more intensive mental health treatment.