A woman with intellectual disabilities choked to death on a waffle at a Northeast Philly group home

Paula Freid choked to death at breakfast Easter Sunday last year while a caregiver allegedly watched her back from the next room at a Northeast Philadelphia group home.

The 63-year-old with intellectual disabilities had a swallowing disorder and needed to have her food pureed or cut up into small pieces. Plus, her caregivers were required to watch her while she ate.

She died with bits of waffle pulled into her lungs, and an empty stomach.

Deaths such as Freid’s happen about once a month inside Pennsylvania group homes, according to state data showing that Freid was one of 22 people to die after choking on food since state regulators began tracking such deaths in July 2021.

The caregivers at Freid’s home, operated by KenCrest, ignored the instructions in her state-supervised care plan by giving her a waffle torn into pieces too big for her to eat safely. They were supposed to be dime-sized, but some were more than an inch wide.

There is no evidence that an aide on a temporary assignment that morning was trained in Freid’s needs, according to KenCrest’s internal investigation of the death. What’s more, the aide had been warned by full-time staffers to keep her distance from Freid while she ate, the reports say.

Philadelphia-area advocates for people with intellectual disabilities described choking deaths such as Paula Freid’s as “distressingly common,” and evidence of a long-term systemic failure to protect the 12,000 people living in Pennsylvania’s 6,000 group homes, much less to ensure they have fulfilling lives in the community.

In Freid’s case, an added level of state oversight still did not prevent a death. Freid received special monitoring under a landmark federal 1980s civil rights settlement that led to the closure of Pennhurst State School and Hospital, a Chester County state institution known for its inhumane and dangerous conditions. Freid was on the Pennhurst waiting list when it closed in 1987.

Now, Freid’s younger brother, Randy Freid, is suing KenCrest; the staffing agency, U.S. Medical Staffing Inc.; and the three caregivers present when his sister died, alleging that his sister’s death was caused by “grossly negligent, careless and reckless conduct.”

“From looking at the coroner’s report, it must have been excruciating for her,” Randy Freid, 60, said during a telephone interview, audibly struggling to keep himself from crying. “What I want is this not to happen to another person.”

KenCrest, a nonprofit based in Blue Bell with 30 group homes in the Philadelphia region, said it could not comment because of active litigation. U.S. Medical Staffing, based in Philadelphia and at least partially owned by a private equity firm in Omaha, Neb., declined to comment, citing the same reason.

Asked whether KenCrest had faced any consequences related to Paula Freid’s death, the Pennsylvania Department of Human Services, which regulates group homes for people with intellectual disabilities, said it could not comment on an open investigation.

The state provides far less public access to records of group home inspections than it does of nursing homes or personal care homes, making it hard to evaluate KenCrest’s track record.

A national study published in 2021 found that people with intellectual disabilities are 26 times more likely to die from choking than the broader population.

“It’s more common than you think, which is distressing,” said Tim Greusel, a longtime advocate for Pennsylvanians with intellectual disabilities.

The study did not address how often choking deaths are caused by caregiver negligence. The Pennsylvania Department of Human Services regulates group homes for people with intellectual disabilities and started requiring operators to report choking incidents in 2021.

The deaths don’t always involve food. A longtime resident of Merakey Woodhaven, in Northeast Philadelphia, Cheryl Yewdall, died last year after being found lying in a pool of urine with a cleaning wipe stuck in her trachea.

Freid’s problems with swallowing, a condition called dysphagia, were well-known, according to Greusel, who was familiar with her situation through his role as monitor of people in Philadelphia and Chester Counties under the 1985 Pennhurst settlement.

Although Freid never lived at Pennhurst, she was included in the group because she was on the waiting list for Pennhurst. Because of that status, Freid also had a state-paid advocate in Pennsylvania’s Office of Developmental Programs.

Supervision while eating is always a component of caring for people with a swallowing disorder, according to Greusel. “It might be direct hands-on. It might be tableside, it might be arms-length,” he said.

KenCrest’s investigation records show that two KenCrest employees present when Freid died were familiar with her dietary needs. But records also offer no evidence that the third person, a temp from U.S. Medical Staffing who was supposed to be watching Freid, had ever been trained to care for Freid.

Paula Freid’s death is horrifyingly similar to what happened in 2017 at another Philadelphia operator of group homes, said Leonard G. Villari, one of her brother’s lawyers.

Blossom Philadelphia, a Chestnut Hill nonprofit operator of group homes, lost its license after it fired its entire staff and hired a staffing firm — now owned by U.S. Medical Staffing — to supply workers for its 32 properties.

On Dec. 31, 2017, just days before Blossom was to turn over a South Philadelphia group home to a new operator, a temporary worker served one of the residents, Vincent McNamara, 60, a slice of Ellio’s pizza, even though he was supposed to have only soft or pureed foods.

The McNamara family’s lawsuit said McNamara choked for at least 15 minutes and went without oxygen for five to nine minutes. Court records show that the family’s two wrongful death lawsuits, one against Blossom and one against staffing companies, were settled for a combined $4.5 million.

“It is utterly infuriating that choking deaths and near fatal injuries are still routinely occurring in the residential group home setting,” said Villari, whose firm also handled the McNamara case.

People such as Paula Freid and Vincent McNamara too often are a “forgotten segment of our community,” Villari said. “We hide them away and we don’t act when they are harmed.”

Contracted, temporary staff are a red flag for Kathy Sykes, a former director of intellectual disability services in Philadelphia still active in advocacy work. “To me, that’s just the worst. When you have contracted staff, you just can’t assure the same kind of continuity,” she said.

Randy Freid was 12 when his sister, who was born with moderate to severe intellectual disabilities, went to live at Woodhaven Center, then a state-operated facility.

“I thought Woodhaven was horrible when I went to visit my sister there as a kid, but I’ve been told that it was a country club compared to the way people like my sister were treated prior,” he said.

KenCrest took over her care in 1995, first in a group home on Primrose Road in Northeast Philadelphia. The agency moved her to her final residence on Lawndale Avenue during the fall of 2017.

“We could see a difference in the care that she was being given, even though it was the same company,” he said.

Freid said his sister, before she needed a wheelchair, loved dancing to such oldies as “Great Balls of Fire.” She loved dolls, he said, and had a collection of 20 or 30 in her room. Her mother put two of them in the casket with her.

The day Paula Freid died, her brother was upset that police quickly declared it an accident.

“If there was a 6-year old child who had choked to death, that would have been a different amount of attention than to my sister,” Randy Freid said.