The Arkansas Department of Human Services (DHS) has launched an investigation into the death of an adult resident at the Southeast Arkansas Human Development Center (SEAHDC) in Warren following what the agency described as a “behavior incident” last month.
According to a DHS news release, the incident occurred on September 7, 2025 and involved the use of both physical and chemical restraints by staff members. A subsequent review determined that employees at the Warren facility did not follow proper protocol during the encounter.
As a result, eleven DHS employees have been placed on administrative leave, one additional employee has been terminated, and the department has appointed an interim superintendent to oversee operations at SEAHDC while the investigation continues.
In a statement released Thursday, DHS Secretary Janet Mann expressed condolences to the family of the resident and described the situation as “wholly unacceptable.”
“The loss of one of the residents entrusted to our care at the Southeast Arkansas Human Development Center was wholly unacceptable and is not reflective of the level of care we work to provide Arkansans every day,” Mann said. “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.”
Mann said the department is limited in what information it can share while the investigation remains active and to protect the privacy of the deceased resident. However, she noted that the internal review revealed “significant issues throughout the handling of this case.”
“As a result, we have placed multiple employees on administrative leave, already fired one employee involved, named an interim superintendent, and are working to implement reforms so our residents receive the proper and safe care they deserve,” Mann said.
The DHS statement added that further disciplinary measures may be taken against any employees found to have violated policy. The department also plans to implement system-wide reforms at all five of Arkansas’s Human Development Centers to ensure consistent safety and quality-of-care standards.
According to the official incident report released by DHS, the findings are based on multiple interviews with both staff and residents, as well as a review of available camera footage. The report provides a detailed account of the events surrounding the September 7 incident.
The report states that a chemical restraint of Geodon, 20 mg intramuscular, was administered to the resident identified as Resident No. 1 (R1). The EMS report included in the file stated:
“Resident No. 1 is pulseless and apneic. Pupils fixed and dilated. Facility staff reports patient became combative and was attempting to bite other residents. Staff first attempted physical restraint which was ineffective, Geodon was administered as chemical restraint. Staff has no idea at what point the patient stopped breathing and lost pulse. EMS continued CPR with chest compressions. AED pad had to be reapplied in the proper positions as they were initially over the abdomen…”
An interview with Resident No. 2 (R2) detailed further concerns about the restraint process:
“I was sitting on the couch with a CNA and Resident No. 1. R1 had grabbed a CNA’s hair and tried to bite her neck. I went outside to get help. R1 was lying face down and when they repositioned R1 onto their back, something wasn’t right — R1 was not breathing. I told the staff that R1 was not breathing and no one responded.”
A Quality Assurance Coordinator (QAC) who reviewed the camera footage confirmed that the restraint was performed incorrectly, stating that:
“The restraint being used was incorrect due to R1 being on their stomach (prone position). The CNA’s hold should have been on the shoulders or wrists, not on R1’s back.”
The QAC added that pressure applied to R1’s back could have restricted breathing.
An interview with a licensed practical nurse (LPN) documented the following:
“After returning to the unit, a registered nurse and staff rolled R1 and administered an injection to the right hip. There had been no pulse or response from a sternal rub. 911 was called, the RN began CPR, an AED was retrieved by me, and EMS took over upon arrival.”
A Registered Nurse Manager told investigators:
“I don’t know if R1 was unconscious or deceased, but I do know R1 was not having a behavior incident at that time.”
The facility administrator, in an interview contained in the report, stated that while there might not be a “legal argument for abuse,” some staff were clearly negligent in their actions.
Text messages between an RN and an APRN included in the incident report also referenced that R1 “was in a burrito (humane wrap) and was being combative and aggressive and not calming down with redirection.” However, upon reviewing the video footage, the QAC noted that R1 was never placed in a humane wrap.
The Warren Police Department confirmed that they did not handle the investigation and offered no comment on the incident. The Arkansas State Police, Troop F, has been contacted for information, but as of press time, no statement has been received.
The Eagle Democrat has filed Freedom of Information Act (FOIA) requests with both the Arkansas Department of Human Services and the Arkansas State Police seeking documentation and reports related to the September 7 incident. The Eagle Democrat will continue to follow this story and publish verified updates as additional factual information becomes available.
The Southeast Arkansas Human Development Center, located in Warren, serves adults with intellectual and developmental disabilities from across the region. DHS officials said additional details will be released as the investigation progresses.
All quotes and information in this story are based on the official DHS incident report released in October 2025 and related agency statements. The link to the incident report can be found here.
