When nine-year-old Carolyn Montes talks about her Uncle Julio, she can't help but smile.
"I would win on tag. He would win on hide and go seek."
No stranger to winning, Julio, a multi-sport Special Olympics athlete made it all the way to the World Summer Games in Dublin, Ireland. He won multiple medals there including three gold, one silver and one bronze.
Julio was born with a brain defect that left him with the mental capacity of a ten-year-old. He went through life with the innocence of a child but the drive to compete. He had love for all around him.
"He'll hug you... just, you're my best friend. That's what he tells everybody." That's how Hector Montes, Julio's brother described him.
Bill Rohret was Julio's Special Olympics coach for 12 years. Julio was in the golf program, basketball, and track. "Great person, Just... he's one of those people who when he'd walk into a basketball practice, everybody would stop and go Julio!" said Bill.
To his mom Carolyn, Julio was the most special member of their family. "He would say, I look handsome, don't I mom? And I would just straight out start laughing."
There will be no new memories to laugh about and no more Special Olympics medals to celebrate. Instead, they have tears for the family member they loved and lost.
"My brother's not... he's not here. He's not going to be able to see them grow up," said Hector.
Soon after his 33rd birthday, Julio went into the hospital. His family didn't know what happened, why or how it could have occurred. That's because Julio had been living for four years at a taxpayer-funded state-run home for mentally disabled people.
State records describe what happened to Julio.
On November 22, on the way back from a Special Olympics bowling competition Julio got into a fight with another patient. The fight stated in the group home's van and Julio was repeatedly kicked and punched in the chest, face and head. That night, the impression of a shoe print was clearly visible on his chest.
Julio had a shunt in his brain and a blood disorder which put him at a higher risk for clots. He was having episodes of nausea and vomiting after the fight and his skin was reddening.
Despite knowing all of that, state records show that the nursing staff did not contact a supervisor or doctor. They didn't consider the event serious and did not monitor him overnight. The next day, he was unresponsive and taken to the hospital. Doctors found bleeding on the brain.
Julio spent weeks in a coma and had multiple surgeries. His life support was ended on December 4.
"I guess the doctors said that he was brain dead, so that was the last time I ever saw him," said Hector.
There are many ways that the state says Desert Regional Center failed Julio.
- Staff in the van failed to stop the fight.
- Nursing staff failed to notice how serious his condition was.
- A tech who saw him lying on the floor in the middle of the night failed to notify a nurse.
- An internal memo shows his bed check form was falsified.
"When you're taking care of somebody with special needs, things like this shouldn't happen," Bill Rohret added.
The coroner says Julio died from blunt force injury of the head, a homicide. The Las Vegas Metropolitan Police Department's abuse and neglect section is reviewing the case, which will be submitted to the district attorney.
No one from Desert Regional Center would talk on camera. State records show one employee was transferred to a department that doesn't work directly with patients. Two nurses were reported to the state board for suspected malpractice. One of them resigned from Desert Regional Center before they could take disciplinary action.
As for the family, tears continue to flow and questions remain, but one thing is certain.
"Whatever just happened to my little brother, they should be accountable or it. The state should be accountable for it," Hector said.
Contact 13 examined hundreds of records showing Desert Regional Center has been in trouble with the state multiple times for abuse and neglect.
Previous incidents at Desert Regional Center
On 2/10/13 staff progress notes documented blood on a client's forehead, down his face,on both sides of his nose between his eyes, in the mouth, on his shirt, boxers and on the floor. He reported being hit in the face with a three-hole punch by the graveyard staff. Stitches required for forehead laceration. Client said he did not feel safe in his home, "because my head was split open for no reason." Worried it would happen again. On 5/3/13 the residential director acknowledged the abuse had been substantiated by the Mental Health Division investigative report.
On 2/21/13 an employee used excessive force to remove a client's head from her chest during a bite. Alleged abuse wasn't reported timely.
In November 2014, Metro issued a card to the facility saying client bit employee and employee slapped the patient. Employee slapped patient with open hand on the left side of her face.
In March 2015, a Medicaid recertification survey said that the facility failed to ensure a client with an intellectual disability was receiving active treatment services. A patient left in bed most of the time instead of getting out, playing games, etc. One employee said it would be impractical to take her out due to needing too many staff members.
Details from a plan of correction submitted to the state by Desert Regional Center
"All residents have the potential to be affected by peer to peer aggression."
One employee reassigned to a department that doesn't work directly with clients. Another sent to be re-trained.
New transportation and charting policies.
Many other policies and procedures revamped and updated.
Employee #10 (RN) resigned her position prior to them taking any disciplinary measures. The State Board of Nursing was notified of suspected malpractice prior to resignation. Also notified in the case of the LPN.