Records show investigations by California state regulators and local police into a beating at the Porterville Developmental Center in 2010 – in which witnesses reported nursing assistant Erik Hansen allegedly stomping a patient unconscious – were beset by lengthy delays and shoddy work.Michael Fagans / The Center for Investigative Reporting

Erik Hansen went by the nickname “Big E” inside California’s Porterville Developmental Center, a nod to the nursing assistant’s 400 pounds and 6-foot-3 frame. He amassed an outsized reputation for menace as well.

His personnel file contains six allegations of physical abuse against patients at the Central Valley institution, which houses 425 men and women with cerebral palsy, mental retardation and other disorders. Between 2007 and 2012, six patients accused Hansen of violence – including rape, choking and battery, according to internal documents from the California Department of Public Health.

Hansen never has faced criminal charges.

Records show the investigations by state regulators and local police into a brutal beating at Porterville in late 2010 – in which witnesses reported Hansen allegedly stomping a patient unconscious – were beset by lengthy delays and shoddy work. The public health department waited more than a year to start interviewing witnesses about Hansen’s role in the incident.

Further hindering the case, several Porterville center nursing assistants and psychiatric aides at the scene dodged interviews with regulators or provided unreliable answers. The Tulare County district attorney declined to file criminal charges against Hansen, citing a lack of evidence.

Almost three years later, state regulators have yet to penalize the Porterville center for exposing the patient to potentially fatal injuries. The public health department has “substantiated this complaint and is in the process of citing the facility,” Anita Gore, an agency spokeswoman, said in a prepared statement.

Hansen’s record at Porterville was obtained from a source by The Center for Investigative Reporting and offers a disturbing glimpse into how the state investigates violence and abuse within the walls of its five board-and-care homes for the developmentally disabled.

None of the agencies responsible for safeguarding vulnerable patients functioned properly in this case, documents and interviews show.

A state report calls Hansen “not trainable” and prone to violence, and it cites numerous complaints against him. The California Department of Public Health revoked Hansen’s nurse assistant license in April 2012. The Porterville center fired him shortly thereafter, personnel and regulatory files show. 

That judgment could become just a temporary setback in his health care career.

Hansen is appealing to regain his license. If successful, he would be eligible to return to his job caring for the Porterville center’s patients. Hansen did not respond to multiple interview requests made to his lawyer, Steven Bassoff.

In a written statement Hansen gave to public health department investigators, he denied “any physical abuse of kicking, stepping or applying force” to the patient. Hansen claimed that a shoe mark left on the patient did not match his shoes.

“Hansen claims that the containment was as close to protocol as possible with two persons one on each arm,” the report reads. “Hansen states, ‘At no time did I feel as though the client was abused or endangered.’ ”

In a series of stories over the past two years, CIR has detailed systemic failures by California officials and law enforcement to pursue justice in violent crimes against the disabled, the elderly and the sick. Hundreds of cases of battery, sexual assault, torture and suspicious deaths at health care facilities across the state have been ignored or received incompetent examination.

The reports of inadequate investigations into abuse have alarmed lawmakers.

“I have grave concerns about the slow investigations by the developmental center and the culture of silence that appears to exist,” said Assemblywoman Connie Conway, R-Visalia, whose district includes the Porterville center. “The fear of retaliation has led to a web of lies, cover-ups and injustice.”

Employees offer conflicting stories

Roughly 200 patients at the Porterville center live in fenced, prisonlike units for “secure treatment.” California’s courts have ruled these patients unfit to stand trial and some a danger to themselves and others. Called forensic patients, they are confined indefinitely.

The afternoon of Dec. 11, 2010, Hansen argued and physically struggled with patient Larry Russell in one of the secured residences. The altercation ended when Russell stopped breathing and lost consciousness. Bruises shaped like boot prints formed across his torso, according to the public health department report.

Medics resuscitated Russell, who is diagnosed with moderate mental retardation and paranoid schizophrenia, regulatory records show. But the patient remained comatose for a week and a half. CIR was unable to locate Russell’s conservator or relatives for comment. CIR also could not verify Russell’s age. Because he is a patient, that information is confidential, according to state law.

A double fence encircles the “secure treatment” section of the Porterville Developmental Center. California’s courts have ruled the roughly 200 patients housed here unfit to stand trial and some a danger to themselves and others.Michael Fagans / The Center for Investigative Reporting

Nearly every other detail about what took place is in dispute.

Hansen, 31, said he restrained Russell against a wall and tied him up to quell the patient’s outburst. He otherwise denied harming Russell in several interviews with police and regulators, records show.

According to internal records of Hansen’s statements, Russell was agitated and pacing the hallway around 3:45 p.m. in a secured residence, craving a cigarette, or “niccing,” as it’s called at Porterville. The patient had gone outside for a smoke break an hour earlier. Hansen told Russell he couldn’t leave the building again.

Russell then acted out, Hansen said, attempting to spit on him. He maneuvered to avoid the spit and, with the help of nursing assistant Jennifer Thompson, moved in to physically control the patient.

Russell struggled against them, Hansen told an in-house investigator at the Porterville center. “It was pretty intense,” he said.

The nursing assistants pushed Russell flat on his back against a wall and bound him. He relented. “During containment client went limp, appeared to lose consciousness and was lowered to floor,” the Department of Public Health report said.

In Hansen’s version of the events, the situation became grave suddenly. The Porterville center incident report said caregivers restrained Russell, he “then stops breathing and goes into cardiac arrest.” State officials blacked out the rest of the document released to CIR, citing patient confidentiality.

Paramedics rushed an unconscious Russell to Sierra View District Hospital. Hours later, Thompson gave a written statement to Porterville center administrators echoing what Hansen said.

Five other employees were working nearby during the incident. Each submitted written notes that day to Porterville center officials that supported Hansen or denied seeing what happened.

In later interviews with police, however, Thompson gave a starkly different, more violent description of the scene, regulatory records show. Neither she nor Hansen attempted to place Russell in restraints that afternoon. Hansen instead knocked Russell onto the floor and proceeded to beat the patient.

Thompson said she and several psychiatric aides pleaded with Hansen as he struck Russell with his feet again and again.

“I told him to stop, I told him to stop and he wouldn’t stop,” records show Thompson recounted. “We were all telling him to get off (Russell). We were yelling at him to stop.”

Russell scrambled onto his stomach and looked to crawl to safety. Hansen pinned the patient with one of his knees, leaning his weight on Russell’s back, Thompson said.

The patient went still. Thompson and Hansen flipped Russell and watched his face turn a sickly blue.

Thompson declined requests for an interview.

Delay in contacting police

No one hurried to call police.

The Porterville Police Department received notice of Russell’s life-threatening injuries 52 hours later, the evening of Dec. 13, records show. The incident is listed in police documents as “suspicious circumstances.”

Russell regained consciousness Dec. 21. Porterville Detective Matt Green immediately went to interview him at the hospital, where a breathing tube limited Russell to shaking or nodding his head in response to questions. But he did not identify the person who assaulted him, records show.

The patient “was aware that he had been assaulted and he knew who did it,” the public health department report said, “but refused to identify the person or persons.” Records show Russell, who still lives at the center, later named Hansen as his assailant.

As Russell awoke, an anonymous employee at the center called Green to accuse Hansen of patient abuse. The story about wall restraints was fabricated, according to the Department of Public Health report.

Green took the tip and questioned Thompson about her initial statement. She confessed to lying and accused her colleagues of orchestrating a cover-up.

The other Porterville center employees’ statements repeatedly contradicted one another.

For example, the residence has a “crash cart” with equipment and supplies for medical emergencies. Three caregivers said they pulled the cart to employees performing CPR on Russell. But only one of them could have undertaken the task.

The statements “do not bear out under scrutiny,” Linda Curtis-Smith, a Department of Public Health investigator, wrote in the case report. Thompson “feared retaliation from her co-workers, since she had broken the ‘agreement’ they had constructed.”

She had more to fear from state regulators. The Department of Public Health, confident that Thompson now was telling the truth, revoked her nursing assistant license because she failed to quickly report the patient abuse.

Thompson won back her license on appeal this year and is again eligible to work for the institution, according to the State Personnel Board.

No charges filed

The Porterville Developmental Center houses 425 men and women with cerebral palsy, mental retardation and other disorders. It is one of five state-run board-and-care homes for the developmentally disabled in California.Michael Fagans / The Center for Investigative Reporting

Another month passed before Hansen faced questioning about the alleged abuse.

Green, the Porterville detective, and the nursing assistant met on Jan. 25, 2011. Hansen flatly denied hitting or kicking Russell, records show. Green forwarded the criminal investigation of Hansen to Tulare County prosecutors two days later. They deemed the evidence too weak and did not file charges.

Porterville police declined to comment. Green has left the department and could not be reached.

California’s developmental centers have an in-house police force called the Office of Protective Services that kept its investigation of Russell’s injuries open far longer, though with identical results. In July 2011, internal records show that investigator Eugene Alvarez interviewed Hansen. His responses remained consistent.

When Alvarez asked Hansen about the accusations against him, he answered: “I have no clue.”

The Porterville center’s internal police department appears to have done little more than accept and review written statements in the case, documents show. It closed the case without making an arrest.

The Department of Public Health did not pursue the allegation until 14 months after Russell went into a coma, regulatory records show. Agency investigators Curtis-Smith and Stacy Corrales arrived at the Porterville center Feb. 10, 2012, to question everyone involved.

Hansen called in sick that day, and two of the witnesses were “unavailable,” according to the department report.

By that date, Hansen was the suspect in a new abuse case.

Porterville center administrators prohibited Hansen from having contact with patients following the altercation with Russell, said Christina Morales, a lawyer for the state Department of Developmental Services, which operates the institution.

The prohibition was ineffective. The internal report shows that in January 2012, a patient’s father saw Hansen shoving his son into a wall. When the father complained, Ricky Esquivel, a supervisor at the Porterville center, reportedly denied that was abuse.

“Don’t worry about it,” Esquivel said, “it’s just horseplay.”

Russell’s injuries, combined with numerous other abuse allegations, were sufficient for regulators to bar Hansen from California health care facilities in April 2012. “Hansen has demonstrated that he is not trainable,” the state’s report said, “and is a threat to the health, safety and welfare of patients.”

But at hearings on Hansen’s appeal earlier this year, the Department of Public Health dropped its argument that Hansen assaulted the patient, instead seeking to uphold the revocation for his alleged use of illegal restraints.

However, internal records show a hole in that argument. 

Russell’s injuries suggest he was on the ground – not bound to a wall – when he sustained the blunt-force traumas. The boot print bruises were on his chest, right arm and groin, places that would be difficult to stomp if Russell were standing.

None of the investigators – not the Office of Protective Services, the Porterville police or the Department of Public Health – collected physical evidence to support the claim that anyone tied up Russell. The charge rests solely on statements from Hansen and other employees at the institution.

This story was edited by Robert Salladay and copy edited by Nikki Frick and Christine Lee.

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Ryan Gabrielson

Ryan Gabrielson is a reporter for ProPublica covering the U.S. justice system. In 2013, his stories for the Center for Investigative Reporting on violent crimes at California’s board-and-care institutions for the developmentally disabled were a finalist for the Pulitzer Prize for Public Service.

Previously, he was a reporter at the East Valley Tribune in Mesa, Ariz. In 2009, he and Tribune colleague Paul Giblin won a Pulitzer Prize for stories that exposed how immigration enforcement by the Maricopa County Sheriff's Office undermined investigations and emergency response. Gabrielson's work has received numerous national honors, including two George Polk Awards, an Alfred I. duPont-Columbia Silver Baton, the Al Nakkula Award for Police Reporting, and a Sigma Delta Chi Award. He was a 2009-2010 investigative reporting fellow at UC Berkeley.

A Phoenix native, Gabrielson studied journalism at the University of Arizona and now lives in Oakland with his wife and two daughters.