The Arizona Republic, August 30, 1998
Chief admits tragic fumble--Staff 'thought this kid was a malingerer,' he says By Dennis Wagner
Arizona Boys Ranch president Bob Thomas admitted to state investigators that serious management failures and employee misconduct led up to the death of a 16-year-old Sacramento boy in March.
However, during an interview with Child Protective Services, Thomas suggested that others share blame for the tragedy of Nicholaus Contreraz, who died of lung failure while being forced to exercise at the camp for delinquent boys.
Thomas' comments are drawn from a two-hour interview last month with CPS investigators from the state Department of Economic Security, which Wednesday announced it is denying Boys Ranch's license due to a pattern of abuse and neglect.
Following are excerpts from the man who has headed Boys Ranch for 22 years. Questions from investigators are paraphrased for brevity and clarity; responses are direct quotes.
Question: This is very uncomfortable.
Answer: Well, it's . . . I know where CPS comes from. And I know you've got a tough job. And, uh, there's a lot of mistakes made in this particular incident. But this is not the global program. . . . I mean, we've done a heck of a lot of good work . . .
Yes, a boy died. Yes, we feel bad about it. Yes, we'll live with it the rest of our lives. And, um, gee whiz, I also think our track record is pretty good, and for a lot of years.
Q: Arizona law requires child welfare employees and organizations to protect their clients. Did the Oracle camp supervisor "fail to protect" in this case?
A: Failure to protect? I think no. He was doing his duties, and he did some very good work. (He) was a good staff member. Did he make a mistake in this one incident? Yeah, he did. . . . Was it serious? Yes, it was. But as far as failure to protect, I think our record is second to none. I mean, a lot of people don't like the paramilitary approach and the whole bit. . . . But that's always been a very safe program.
Q: Might Contreraz still be alive today if Boys Ranch had properly cared for him?
A: You could take this one step farther. I mean, you could take Sacramento (County Probation Department). Should they be charged with failure to protect? I mean, should the mother be charged with failure to protect? Should . . . the probation officer be charged? I mean, we're looking at fault. There's enough fault to go around for everybody.
It was a tragedy, and . . . I'm not trying to negate all responsibility for Boys Ranch. . . . (But) what we also found out was, I mean, there was a reason staff, our staff, made drastic mistakes.
Q: Nicholaus Contreraz was sick, uncooperative and suicidal. Why didn't Boys Ranch return him to probation authorities in California?
A: I think what happened was our philosophy of never giving up played against us, and in some way broke our common sense. . . . I don't know what transpired or why we, why we went against good judgment.
I think we were talked out of it by (probation officials) in Sacramento. . . . We were getting ready to terminate that youngster (send him back to California) until they kind of, um, you know, talked us . . . to hang on till . . . death do . . . Yeah, the Last Chance Ranch.
Q: Before his death, Contreraz suffered from vomiting, breathing difficulties, diarrhea and fatigue. Why wasn't his infection detected during repeated visits to a nurse?
A:I think with our nurse, for example, she's taking a lot of heat. And I know she's a very dedicated person. I mean, she was a good nurse. . . . There was nothing she wouldn't do for this kid . . .
Did she make errors? Certainly. She had to make errors in misdiagnosing. Now why she did it, I can't answer that. . . . We dropped the football . . .
Our internal investigation found . . . we feel that our medical department down there (in Oracle) was maybe too close to the program.
Q: Is there a written report based on that internal probe?
A: We had a very extensive . . . three-week investigation. . . . Normally, we'd have it written, but we didn't on this particular time. We just went . . . they briefed me.
(Thomas added that his investigation uncovered a breakdown in supervision, which he blamed on staff inexperience, communication failures and the fact that top managers were focused on other programs.)
Q: Explain why those management lapses occurred.
A: You know, we were really into quality assurance, and we were into goal setting. So we were teaching that, and, frankly, I think we kind of dropped our training with some of our people in orientation. . . . I think we didn't do the oversight of our line staff, who are all less than a year. And I think that contributed.
Q:Talk about the communication breakdowns.
A: Well, first of all, they (staffers) didn't . . . report some of these problems immediately with the young man. And they should report these things immediately. . . . I mean, they were virtually on their own. We didn't have administrative oversight that we needed to check this thing, to lead this case . . .
That was an aberration. We usually have good communication. We have our system down there was new, eight months, and I don't shuck responsibility. . . . And, yeah, we had communication problems. We have problems with DES, there's a chance there are going to be communication problems. And the same thing happened down there. The only unfortunate thing, we had an unfortunate death.
Q: Did you know Contreraz? Did your staff ever mention him to you?
A: No, I never met the young man. I didn't really know who he was.
Q: What was your responsibility as director in regard to a boy who was being considered for termination?
A: I'm in charge of the agency. So I had to be responsible for everything, whether I like it or not.
Q: Explain why Contreraz was forced to carry around a bucket containing his defecation-soiled clothing.
A: I would call that a degrading incident. . . . I pulled this (staffer) in because I wanted to talk to him. I said, "Where did you learn this?" That was, I mean, we don't teach these things in training, and he admitted, no, he didn't learn this in training, and he just didn't have an answer for me. . . . I can't fathom why anybody would do something like that . . .
In my opinion, these are good people. . . . They broke policy, but they meant well. They aren't bad people. They had no intent to hurt this kid. They truly thought this kid was a malingerer.
Q: What about testimony that Contreraz was forced to eat his lunch while sitting on a toilet?
A: I think, uh, just because he (the supervisor) was short-staffed. I don't think they really meant to be degrading to him (Contreraz) at that particular time. . . . And, you know, what makes this so doggone tough, too, is (the boy's constant vomiting and diarrhea). . . . You know, when he got mad, I guess he would do things like this. And I'm not making excuses for staff, but . . .
Q: The medical examiner discovered 71 bruises, scrapes and other wounds on Contreraz's body. Where did they come from?
A: I mean, there were just an awful lot of marks, and probably from the CPR being performed by, a lot of it in the sand (inaudible) for close to an hour. I mean, some people bruise easy. You know, it's a physical program.
Q: Did your internal investigation consider the possibility that staffers used excessive force?
A: We looked at, yeah, certainly. . . . Actually, I mean, he (Contreraz) just flat refused to do a lot of things (work and exercises). . . . If anything, his last day, it was just hold him by the belt and, you know, trying to get him to do push-ups . . .
It's very difficult to determine was it excessive force, or was it staff just going with the program to physically assist, which is part of our program. We've made no bones about that. You know, we've tried to encourage, motivate. . . . And was it part of that? Or was it part of somebody really abusing somebody?
Q: Discuss your philosophy of working with young men.
A: We're the last opportunity for these kids . . . prior to going through some type of public correctional facility. . . . We've always treated kids with dignity. It doesn't mean you don't confront them, and you can't be afraid of them. . . . Ninety percent of our problems are inmates from orientation (at the Oracle campus). Always have been. Probably always will be. I mean, that's when the kids haven't made a commitment. They want to get out of the program. . . . They are used to manipulating the system, beating systems. . . . But once you get them through that, I'll tell you, once they buy in, they see the wagons are circled and they have to . . . there's only one way out - that you have to start achieving.
Q: What type of boys do you recruit?
A: (Thomas said the vast majority of placements are serious offenders from broken families - minorities from the barrios and ghettos of California.)
If I've learned anything from this business, these kids are as normal as any group of kids at Mountain View High School. They can perform well. The only thing about it is they're behind. And they're intelligent. . . . They just never believe in themselves that they could do it. And I think if we do anything at boys Ranch . . . we just have a belief that we're going to work with you. We're not going to give up on you, and we're going to see you to the glory land.
As the interview ended, CPS investigators notified Thomas that, as director of Boys Ranch, he could be named as a perpetrator for failure to protect Nicholaus Contreraz. Thomas was not among the 17 Boys Ranch workers state investigators say contributed to Contreraz's death through neglect or abuse.
Boys Ranch is appealing the revocation of its license. Although its enrollment has been depleted, it will remain open while the case is under review.
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Dennis Wagner can be reached at 444-8874 or at firstname.lastname@example.org via e-mail.