Mistreatment routine, report says
By Pat Flannery
The Arizona Republic
Aug. 27, 1998
The number of wounds on the body of the teenage delinquent is a matter of cold medical fact from the pages of an autopsy: 71. Blunt force injuries. Bruises, cuts and abrasions from head to toe.
Arizona Boys Ranch officials maintain that it was an aberration. Five Ranch employees were fired and several others were suspended for violating Ranch policies in the Nicholaus Contreraz tragedy.
But state investigators, after three months of probing, say 17 employees contributed to his death through neglect, abuse or simply turning a blind eye to the actions of others.
Boys Ranch officials Wednesday vowed to fight the findings of the Department of Economic Security's newest report, which rejects their claim that the California youth's death March 2 was a result of isolated incidents and mistakes.
Calling the death "regrettable and tragic," Ranch officials said they had conducted their own review, which resulted in "a number of decisive and ongoing remedial actions" that included suspensions and firings.
"Upon learning of policy violations by staff, ABR accepted responsibility for actions, apologized and promptly began instituting corrective action," a prepared statement said.
Yet state investigators say it was an abusive culture that led to Contreraz's death and left other residents of the home for troubled youths captive to routine mistreatment or injury. State officials, who also announced Wednesday an effort to deny renewal of Boys Ranch operating license, said those problems continued unabated even after Contreraz died and investigations began.
The DES findings echo those of a California Department of Social Services investigation, which concluded last month, that youths were being abused. California has halted funding for the placement of delinquents there.
Connie Woodward, Contreraz's grandmother, praised the decision but said "there's no closure, because there are still no arrests."
"But it's a beginning, where we had nothing before."
Of the 17 former employees mentioned by DES, five were fired by Boys Ranch for violating Ranch policies. One resigned and 11 others have been laid off as the resident population has dwindled after Contreraz's death.
Woodward and Julie Vega, Contreraz's mother, on Wednesday visited the Sacramento cemetery where Contreraz is buried to deliver a new teddy bear and "to talk with Nick and let him know that we're getting there."
| TIME LINE |
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| 1971 - House parents report Boys Ranch staff assaulted kids. House parents fired. State revokes ranch license then reinstates it. 1982 - DES issues 500-page report on discipline violations. Ranch experts dispute the findings. 1987 - DES investigates abuse claims. Corrections Department substantiates some complaints. Ranch administrator Bob Thomas says findings come from manipulative youth and inept regulators. 1994 - A California judge complains of "systemic abuse." A youth drowns attempting to escape. DES substantiates 13 abuse cases, but experts hired by Boys Ranch say state investigators are biased. March 2, 1998 - Nicholaus Contreraz dies after being forced to exercise. Initial Boys Ranch inquiry finds no wrongdoing. New director of Oracle camp acknowledges mistreatment. March 4 - California suspends funding for new placements at Boys Ranch. April 27 - Ranch officials concede Contreraz was mistreated. They replace the director and fire two staffers and suspend four. May 2 - DES Director Linda Blessing vows to investigate and close Boys Ranch if a pattern of abuse is documented. July 1 - DES extends Boys Ranch license until investigation is completed. July 7 - California authorities conclude medical neglect and physical abuse led to Contreraz's death and cut off funding to Boys Ranch. July 29 - The FBI and Justice Department confirm investigations into the death of Contreraz. Wednesday - DES announces it will not renew the Boys Ranch license. VIOLATIONS Nicholaus Contreraz was not the only resident mistreated by Boys Ranch staffers, according to the Department of Economic Security. Other violations disclosed in Wednesday's DES report included: November 1997: Resident received injuries from staff including a black eye and abrasions on his cheek, chin, eye and forehead. Feb. 16, 1998: Resident was "physically restrained by ABR staff during which his face was slammed into the floor and he received a swollen eye and face, busted lip and bloody nose." April 6: Resident was restrained to the ground by staff and had his face rubbed in sheep manure. Mid-April: Resident hospitalized with a swollen left elbow, scrapes to his right shoulder, lacerations behind both ears, swelling and a scrape to his forehead, and other injuries after a "physical intervention" by staff. Late April: Resident slammed into a table by workers, injuring his back and neck. Boys Ranch failed record or report numerous incidents, including more than a half-dozen injuries resulting from physical restraint; a resident's hospitalization for a contagious disease and a head injury that left him unconscious; and the injury in April of a resident whose head was stitched up after being hit by a rock thrown by a ranch worker.
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"Charges should have been filed the very day Nickie died," Woodward said.
Contreraz was placed at the Ranch's Oracle facility Jan. 5 by the Sacramento Juvenile Probation Department after a series of personal problems that intensified when his father was killed in a drive-by shooting in 1994.
He had a delinquency record that included shoplifting and attempted robbery.
Only two months into his stay in Arizona, Contreraz died after days of severe illness that went largely untreated even though he continually complained of feeling ill.
An autopsy revealed that he died from complications of empyema of the left chest. He couldn't breathe because, as medical examiners later found, there were 2.5 quarts of pus between the lung and the inside lining of his chest cavity.
Documents released Wednesday by Blessing add to the weight of evidence indicating Contreraz was victimized before he died March 2.
For example, he had "approximately 70 blunt force injuries to his body consisting of abrasions and contusions on his chest, abdomen, back, shoulder, chin, knees, arm and head which were inflicted from "assisted exercise" and "restrictive behavior management" incidents," said a DES notice sent Wednesday to Boys Ranch.
The notice said Boys Ranch "verbally abused, ridiculed and humiliated him by forcing him to carry a bucket with his vomit and clothes on which he had defecated, by periodically forcing his head into the bucket to smell the vomit and defecation, by forcing him to eat meals while seated on the toilet."
The notice said staff ignored "his cries for help and his medical symptoms including his loss of appetite." The same document said he was sometimes laughed at while vomiting, as staff accused him of faking an illness to avoid tough physical exercise.
As his condition worsened, Contreraz talked of wanting to die, according to a Child Protective Services investigative report.
A day-by-day and hour-by-hour reconstruction by CPS of his last weeks alive paint a chilling picture of a boy isolated by staffers, jeered as a laggard and punished because they thought he was pretending to be sick. Names of Boys Ranch employees were blacked out in the report.
Three days before his death, for example, he defecated on himself and vomited. He was suspected of forcing himself to vomit, and was told that he "needed to follow instructions, stop defecating on himself and accept responsibility for his actions." Those conclusions were drawn despite repeated previous visits to the nurse for medical treatment of a variety of symptoms such as difficulty breathing, fever, aches and pains.
Later the same night, he was forced to do exercises and again defecated on himself and said he felt like vomiting. He was "given the opportunity to shower and clean up and physical training resumed."
On the day before his death, Contreraz was unable to eat breakfast and was too weak to do morning exercises. He collapsed after being ordered to run up and down a hill. A few hours later, he again fainted while walking to the chapel. Staffers rolled him to the chapel in a wheelbarrow. He could be heard saying, "Lord help me, I need help, I need help."
By the next day, he was barely able to keep his eyes open and was unable to eat. Before lunch, he was unable to run so staffers "attempted to have the victim run by dragging him while holding him under his arms." He was seen carrying a yellow bucket in which he had been told to vomit or defecate. "He was being marched, was sweaty and his pants kept falling."
At lunch that day, kitchen staff was told to serve Contreraz the bare minimum of food. By late afternoon, staff was again trying to force him to exercise.
"He was isolated following this and a discussion took place in which the victim was informed if he did not perform the exercises, he would be physically assisted," the CPS report states. He was told to do push-ups, but couldn't.
He again defecated on himself, then became belligerent as staff tried to force him to stand and clean himself up. He was carried to a barracks and forcibly showered.
More exercise was forced on Contreraz, with staff lifting him and dropping him to the ground for push-ups. Growing yet weaker, Contreraz's inability to perform as ordered garnered more punishment until he was finally pushed against a wall and yelled at. An employee sleeping 60 to 75 feet from the wall was woken up by the noise of banging on the wall.
Finally, upon being told to do more push-ups, Contreraz lay on his side in the sand and asked for water. He was told to stand, but refused, so staffers carried him by his wrists and ankles to a barracks. A worker went to get water.
When he returned, Contreraz was "unresponsive."
Ninety minutes later, he was officially pronounced dead at a local hospital.
In all, Boys Ranch was found to have repeatedly violated five state regulations in its treatment of Contreraz. While DES has no authority to take action any of the individual former employees cited in its reports, it believes it can substantiate allegations of abuse, neglect and bodily injury against former Ranch employees.
The Pinal County Attorney is investigating and says a decision on whether to file charges will be made within several weeks.