By Spencer Hunt and Debra Jasper
The Cincinnati Enquirer

When Michael Joseph Kelly became violent and tried to hit another resident at a Pike County workshop, five workers held him down on a mat.

He vomited, turned blue and died later that day, Dec. 10, 1998, at age 42. Cause of death was asphyxiation, complicated by vomiting.

An investigation into the death still hadn't been completed six months later, when state health inspectors arrived at Good Shepherd Manor No. 1 in Wakefield, the nursing home where Mr. Kelly had lived.

Workers at the Pike County Board of Mental Retardation said they were waiting for questions from the state. State officials said they didn't have any questions for the county board.

The state Health Department threatened to decertify Good Shepherd in June 1999. Health inspectors said one workshop worker improperly held Mr. Kelly down and cited Good Shepherd for failures to ensure the death was investigated and to make sure all workshop staff were trained in restraints.

While the incident happened outside the nursing home, Good Shepherd was held responsible because it contracted with the workshop.

The state withdrew its threat to decertify Good Shepherd after the home and the county agreed on a new training plan for workshop staff.

Norm Tremblay, Good Shepherd supervisor, says he doesn't think the five-person hold caused Mr. Kelly's death. He also says it wasn't clear who was supposed to investigate.

Madelyn Migyanko, who supervises Pike County mental retardation services, won't comment.

Mr. Kelly's mother, Shirley Ann Kelly of McLean, Va., says she was told her son "had eaten and it went down his windpipe."

"Michael was likeable, he had his moments," she says. "He was well cared for. I have no complaints."

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