The report, which analyzed three years of incident reports from facilities licensed by the Virginia Department of Behavioral Health and Developmental Services, found that nearly half of the reviewed cases involved staff who delayed or failed to perform CPR or call 911 during medical emergencies.

"I believe the majority of them were preventable, at a minimum their odds of survival could have been improved," said Colleen Miller, who heads the Disability Law Center of Virginia.

The analysis uncovered troubling patterns in emergency response protocols. In many cases, staff members called supervisors before emergency services or even left the premises before calling 911.

"We found an alarming number of deaths that seemed to be related to poor staff response to the incident, either a failure

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