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"We know that this drug can slow the heart, which would slow down the breathing," which could cause reduced oxygen to the brain, says Andrews. "It could at least contribute to her death -- if not cause it."
The first thing for investigators to do was to get Jenna's dosage records, which would tell them how much thioridazine Jenna was given, by whom, and when.
"The center has not been able to locate the records," Perper says. "It obviously makes the investigation more difficult and the conclusion more difficult to reach."
Beggs, the center's president, wouldn't comment on the missing records, except to say they weren't crucial, as they would only "show what drugs she was getting." He also said one of Jenna's thioridazine bottles had either been broken or was spilled at the center, though he said he didn't know by whom or exactly when this occurred. There is no record of any spillage, however, and the pharmacist was never informed of it. Michelle Bernardo refused to discuss the case with New Times.
Beggs says a record of a prescription drug being spilled wouldn't necessarily be kept.
"It's conceivable that if a bottle broke, it would be, 'Whoops,' and then we'd call the mom and get another one," Beggs says. "That wouldn't necessarily have to be recorded."
Such records are supposed to be kept at the group home, however. State guidelines dictate that all medication used must be recorded in the group home, which is regulated not by the agency that oversees the main facility but instead by the Department of Children and Families. The director of the center's group homes, LeShawn McCray, said every time Jenna was medicated, all pertinent information -- time, amount, who gave it, et cetera -- was marked on her dosage records. McCray wouldn't comment on why, in Jenna's case, those records are missing.
Kurt Hoppe, the chief local regulator over the group homes for the Department of Children and Families, says he hadn't heard anything about the missing records or the investigation itself. He says that under normal circumstances, his agency would investigate such a matter.
"We would have to review the clients' medications, when they were seen by a doctor; we'd count pills -- there would be a full investigation," Hoppe says.
McCray is in charge of all three of the center's group homes. She is "on call" at the group home where Jenna was staying but doesn't normally work there. The group home is staffed by students and nursing assistants, who make between $7.50 and $10 an hour, McCray says. They generally handle all facets of care at the home, including giving out prescription medications, like the powerful sedative phenobarbital, and, in Jenna's case, thioridazine.
The drugs are kept in the locked cabinets in the home's back room. McCray says that, in addition to herself, only two other staffers -- one of them a nursing student, the other learning to become a respiratory therapist -- have the keys to the cabinets. It's the two students' job to measure out the proper amounts and place them in small cups on a tray, which is stored in the padlocked refrigerator. Every staffer administers medicine, so each has a key to the refrigerator. (Staffers contacted at the group home had no comment about Jenna's case.)
McCray says she's trained all the staffers in how to give medicine. None of the group home staffers, however, would be allowed to handle a bottle of thioridazine, or for that matter any other prescription drug, in a hospital. Only McCray, the registered nurse, would. Group homes in the state of Florida don't fall under the same stringent regulations as other medical facilities.
"Anybody can give it," McCray says. "They do not have to be a licensed professional, unlike a hospital. The guidelines are totally different.... Even my position is not required as an overview. But our board of directors felt that it was important."
Jenna was given a proper amount of the drug, McCray says, once in the morning and once at night. Is it possible that one of the staffers gave Jenna more to keep her from crying?
"She cried all the time, even when we gave her [thioridazine]," McCray says. "We're used to that. We have kids who don't sleep at night and scream and cry for hours. That doesn't bother us. All of our staff is trained to deal with that."
When confronted with the high rate that thioridazine was going through the center and the toxic levels in Jenna's bloodstream, McCray says she is "absolutely, 100 percent positive that Jenna was not overmedicated" at the group home.
Beggs says he's also confident that Jenna wasn't given too much thioridazine at the group home. When asked about the level of training of staff at the group home, he said that he's evaluating the situation and may add licensed staff if it's deemed necessary.
"It's really a matter of economics," he says.
As center staffers learned in the case of Cristal McBean, economics can also play a role -- a $4 million role -- when a relatively inexperienced employee performs a task meant for experienced professionals.