The Arkansas Department of Health released a report detailing a death at a Human Development Center (HDC) in Southeast Arkansas.
HDCs house Arkansans with severe intellectual or emotional disabilities. On September 7th, 2025 a resident died in the Southeast Arkansas Human Development Center, located in Warren, Arkansas.
The 148-page report says the resident died during a physical and chemical restraint. Employees are allowed to restrain residents under certain circumstances, but the report says in this case employees did not follow proper procedures.
The entire incident lasted about an hour, from the restraint after 6 p.m. to the death around 7 p.m.
In the state report, the deceased is referred to only as Resident #1. A second resident, Resident #2 witnessed the incident, and seemingly knew Resident #1 on a personal level.
Resident #1 was 21-years-old when he died. He had “severe” disabilities. The report classifies them as having a seizure disorder, autism and the language equivalent of a two-year-old. Resident #1 had a history of self harm and biting, including biting off “his own mothers thumb.”
Resident #1 required around-the-clock “1:1” care. He wore a helmet to prevent biting, but the helmet was not in the room where the incident happened.
Shortly after 6pm Residents #1 and #2 were sitting on couches in a common area with staff. A Certified Nursing Assistant, known only as CNA #5, was beginning their shift.
CNA #5 was tasked with monitoring Resident #1. CNA #5 talked to Resident #1 about taking a shower. This apparently upset the resident.
“Resident #1 then grabbed CNA #5's hair,” the report says, “and pulled staff toward self,” in an apparent attempt to “bite CNA #5 on the neck.”
During the investigations, CNA #5 said:
"If I had known he was to wear a helmet, I think that would have changed everything and Resident #1 would not have tried to bite me."
The different eyewitnesses, staff and residents, gave similar accounts.
After the attempted biting Resident #1 fell backward and was physically restrained.
The report says there should be a verbal de-escalation before restraining him.
He was held down by CNAs #5 and CNA #8.
CNA #8 said Resident #1 was held face down during the restraint, with CNA #8 and CNA #10 held the Residents arms, no one held the legs. But CNA #10 told investigators something different. CNA #10 said they held the residents head, not arms, while other employees held the legs.
Resident #2 watched from the same sitting room. They left the building to get help returning to see Resident #1 “repositioned.”
At some point, Resident #1 was flipped over. Resident #2 got a bad feeling.
“Something was not right,” he told investigators “Resident #1 was not breathing.”
Video of the incident is not public, but independent investigators who saw it, said it depicted a bad restraint. According to the video, both CNA #8 and CNA #10 put hands on his back. CNA #8 told an alternate story:
“Once, I accidentally placed my elbow on Resident #1's back during the physical restraint and repositioned to correct it,” CNA #8 said.
If staff want to further restrain a patient they can use a “chemical restraint.” This is a drug for sedation. It's only allowed if a doctor or Psychiatric Advanced Practice Registered Nurse okays it. In the report, this person is referred to as PAPRN #21.
Into the room, came a nurse, referred to as RN #7 in the report. RN #7 gave Resident #1 the restraint drug, first asking PAPRN #21.
PAPRN #21 said RN #7 gave them "incorrect" information. Text messages from RN #7 say the resident was in a “humane wrap." The messages say he was “Being combative and aggressive and not calming down with redirection.”
The report says video footage contradicts this story. Resident #1 “was never placed in a humane wrap.”
Even RN #7 said they did not see any bad behavior from Resident #1. They also admitted Resident #1 was no longer “a danger to himself or others,” once they got to the scene.
When the drug was injected Resident #1 didn't need it.
When RN #7 was asked why they administered the drug, they said:
“I am just doing what I am told to do, and if we get an order, then we are required to give the medication.”
The report says, the PAPRN #21 needed an update from the RN on duty.
The employee's behavior is criticized in the report by the facilities nurse manager, a Quality Assurance Coordinator and a Maltreatment Investigator.
Its unclear when Resident #1 died. But the death occurred sometime during the restraint.
Later Resident #2 said he met with Resident #1’s parents after he died. Resident #2 had “written them a letter” and he gave the family “a little toy” Resident #1 liked playing with. The family said they would “place the toy in Resident #1's pocket during the funeral.”
The report says the facility failed on several levels to keep residents safe. Per state policy, HDC clients have rights and faculty are obligated to ensure they are free from abuse and neglect. Meanwhile, there is chronic understaffing at the facility, something discussed at a recent legislative meeting.
In a statement, DHS Secretary Janet Mann called the death: "unacceptable."
"We offer our deepest sympathies to the individual’s family and are working to both hold accountable those responsible for this incident and make changes throughout our system to prevent future tragedies."
Several people are on leave since the incident at the Southeast HDC. One was fired.
In 2020, a different resident died during a restraint at the Boonville HDC. His family was given a six figure pay out by the state.
