BROWNSBORO HILLS HEALTH CARE AND REHABILITATION CENTER
Located: 2141 SYCAMORE AVENUE, LOUISVILLE, KY 40206
On January 22, 2014, the Kentucky Office of Inspector General concluded an investigation at Brownsboro Hills Health and Rehabilitation Center and issued numerous serious deficiencies, including 11 Immediate Jeopardy citations. The Kentucky Office of Inspector General discovered unreported sexual abuse, physical abuse, verbal abuse and neglect and issued a lengthy deficiency report. Due to the length of the report and the amount of deficient practices noted therein, NHAA will post this material in 4 parts. PART 1 CAN BE FOUND HERE.
WARNING: THE FOLLOWING CAN BE DISTURBING TO SOME READERS.
PART 2 OF 4
The Neglect and Broken Systems at Brownsboro Hills
The following highlighted quoted text from the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES is only a portion of the full report/survey. The full report/survey can be found here.
Failure to investigate abuse, report abuse and have systems related to abuse for 14 of 22 sampled residents
Based on observation, interview, review of the facility’s investigation, and policies regarding Resident Abuse and Resident Abuse- Resident to Resident, it was determined the facility failed to have an effective system to ensure policies and procedures were implemented related to abuse for fourteen (14) of the twenty-two (22) sampled residents (Resident’s #1, #2, #3, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19). The facility failed to ensure staff reported allegations of abuse, failed to investigate allegations of abuse, failed to prevent the potential for further abuse, and failed to report allegations to the appropriate State Agencies per the facility’s policy and procedures.
Failure to perform required registry checks, criminal background checks – Director of Clinical Services (DCS) with criminal history of theft
In addition, review of eighteen (18) employee records revealed eight (8) employees files did not contain the required registry checks, criminal back ground checks, and/or references for abuse prohibition. The facility’s failure to implement abuse policies regarding identifying, investigating, reporting, and protection of residents from abuse placed residents in a situation that has caused, or was likely to cause serious injury, harm, impairment or death to a resident.
Continuing: Review of the facility’s policy regarding Eligibility for Employment, reviewed [DATE], revealed any individual who had been convicted of any offense involving theft may not be eligible for hire.
Continuing: Review of the personnel file for the previous Interim DCS revealed the facility hired the DCS on [DATE] and was present during the incident of sexual abuse between Resident #1 and #2. The facility completed a criminal background check on [DATE] that revealed a charge of Theft by Unlawful Taking, disposed of as Indictment by Grand Jury.
Failure to provide baths and showers – Unit manager admits she did not have time to ensure residents were given baths and showers
The facility failed to provide Resident #5, a dependent resident, scheduled showers despite the resident filing grievances for not receiving showers.
Continuing: Review of the Resident Bathing Type by Day Chart, for 10/17/13 to 01/02/14, revealed the resident only had ten (10) days recorded where showers were given with no showers recorded from 12/04/13 to 01/02/14. Review of the Facility’s shower schedule revealed the resident should have received two (2) showers a week for a total of nine (9) consecutively missed showers.
Continuing:Interview with the Unit Manager, on 01/03/14 at 4:05 PM, revealed she did not have time to monitor the shower book or the skin sweeps to ensure the baths and showers were completed.
Continuing: Continued interview, on 01/03/14 at 2:50 PM, revealed she was aware the baths and showers were not always completed and did not monitor SRNA documentation in the kiosk.
Administrative failures to implement policies and systems to protect residents from abuse
Based on interview and review of the facility’s Abuse policy and investigations, it was determined the facility’s Administration failed to ensure the facility policy and procedures were implemented in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. The facility’s Administration failed to have an effective system in place to ensure policy and procedures were implemented to protect residents from abuse; failed to ensure staff was knowledgeable of the facility’s policy and procedures related to abuse; and failed to provide guidance and oversight during abuse investigations. The Administration failed to provide guidance to Social Services to ensure assessments of resident behaviors were completed and care plans updated. The Administration further failed to ensure staff were knowledgeable of resident behaviors, monitored and documented the behaviors to ensure communication to Social Services. The Administration also failed to ensure the residents’ clinical record was complete and accurate related to verbal, physical, and/or sexual behaviors exhibited by the residents.
Failure to supervise residents with behaviors for 15 of 22 sampled residents
Based on observation, interview, record review, and review of the facility’s policy, Accident and Incident Investigation, Behavior Monitoring, and education materials, it was determined the facility failed to have an effective system in place to ensure staff adequately supervised residents with behaviors for fifteen (15) of twenty-two (22) sampled residents. The facility failed to identify and monitor all exhibited behaviors by Residents #1, #2, #3, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and #22.
Failure to have accurate and complete medical records for 15 of 22 sampled residents
Based on observation, interview, record review, and review of the facility’s policy, it was determined the facility failed to have an effective system in place to ensure clinical records were accurate and complete for fifteen (15) of twenty-two (22) sampled residents. Residents #1, #2, #3, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and #22. The facility staff failed to document behaviors of verbal, physical, and/or sexual behaviors toward staff and other residents in the clinical record.
NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately. We can help you file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.
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