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 Centerand 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.
WARNING: THE FOLLOWING CAN BE DISTURBING TO SOME READERS.
PART 1 OF 4
The Sexual Abuse, Physical Abuse & Verbal Abuse at Brownsboro Hills Health Care
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.
SEXUAL ABUSE, PHYSICAL ABUSE AND VERBAL ABUSE INVOLVING A TOTAL OF 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).
Continuing: The facility’s failure to have an effective system in place to ensure residents were free from abuse placed residents in a situation that has caused or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/10/14 and determined to exist on 07/17/13.
Review of a nurse’s note, dated 07/17/13 at 10:25 PM, revealed Resident #1 had been in Resident #2′s room with his/her hand under Resident #2′s sheet touching and fondling Resident #2. The nurse’s note further revealed Resident #2 told Resident #1 to stop; however, Resident #1 continued to touch Resident #2 under the sheet.
Continuing: The resident stated Resident #1 tried to touch him/her two (2) times in the groin area. The resident indicated the touching by Resident #1 made him/her feel uncomfortable
Continuing: The SSD [Social Service Director] stated Resident #2 said he/she did not want sexual contact with Resident #1.
Continuing: The SRNA [State Registered Nurse Aide] indicated Resident #1 had sexually abused Resident #2. On 01/09/14 at 9:01 AM and 10:12 AM, interview with LPN #5 revealed it was sexually inappropriate behavior for Resident #1 to try and kiss Resident #2. She stated Resident #2 could not push Resident #1 away as Resident #2 only had useof one (1) arm
Continuing: Interview with the SSD, on 01/07/14 at 8:57 AM revealed she had observed Resident #1 and Resident #2 kissing each other in the hallway on 01/06/14, but never interviewed to determined if it was consensual and she assumed they were girlfriend and boyfriend. Interview with SRNA #1, on 01/09/14 at 10:20 AM, revealed Resident #1 and Resident #2 kiss often, and she had personally seen them kiss on two (2) to three (3) occasions. She stated Resident #1 always initiated the contact. She stated Resident #2 was moody and the resident did not want the attention of Resident #1, even if they were seen kissing. The aide stated she had seen Resident #2 look like he/she did not want to be bothered by Resident #1. She indicated she had never asked Resident #2 if it was okay for Resident #1 to kiss him/her.
RESIDENT TO RESIDENT ASSAULT RESULTING IN FACIAL BRUISING & DISLOCATED SHOULDER
On 01/09/14 at 3:08 PM, with SRNA #3 revealed she had been outside in the courtyard on 11/05/13 and witnessed the incident between Resident #1 and Resident #3. She stated she heard Resident #1 tell Resident #3 to pull up his/her pants. The aide stated she redirected Resident #1 who continued to aggravate Resident #3. She indicated Resident #3 had become aggravated and raised his/her walker and hit Resident #1 with the walker two (2) to three (3) times, possibly on the arm. She further indicated Resident #3 then lost his/her balance and fell, and Resident #1 attempted to move his/her wheelchair away from Resident #3. The SRNA stated Resident #3 fell with his/her head falling into Resident #1′s lower legs. Additionally, she stated Resident #1 then kicked Resident #3 in the head about three (3) times.
Continuing: A skin assessment of Resident #3, dated 11/05/13, revealed a mark on the left side of the resident’s mouth.
Continuing: On 11/06/13, Resident #1 complained of arm pain and an X-ray revealed a dislocated shoulder. This incident was never reported to the SSA or investigated as abuse.
PHYSICAL ASSAULT OF RESIDENT BY NURSE AIDE
Review of the completed facility investigation, dated 01/06/14, revealed SRNA #2 verbally and physically abused Resident #1 on 12/31/13.
Continuing: Interview with LPN #4, on 01/06/14 at 10:37 AM, revealed she heard screaming, yelling, and cussing down the hallway. The nurse stated she, LPN #2, and LPN #3 all responded, and when she arrived SRNA #2 and Resident #1 were in a fist fight with LPN #3 standing between them. She indicated both the aide and the resident were trying to get at each other, around LPN #3, and were throwing fists at each other.
Continuing: He indicated when he stepped between them both the resident and aide made threatening statements to each other; I am going to get you; I am going to find you
Continuing: Additionally, LPN #4 stated while outside, the aide attempted two (2) to three (3) times to go back into the building, saying she was going to F. you up.
Continuing: The resident stated SRNA #2 then tried to pull his/her hair, and hit the resident on the right side of the face, with a motion of an open claw
Continuing: She [SRNA #2] further indicated she had told the resident at some time during the incident she was going to kick (the resident’s) ass.
Continuing: The LPN indicated she completed Resident #1’s physical assessment after the incident occurred. She stated the resident had slight bruising to the right cheek.
VERBAL ASSAULT BY ACTIVITY DIRECTOR
On 12/30/13, the facility’s Activities Director was observed, by the adult Psychiatric Advanced Registered Nurse Practitioner (ARNP), yelling and screaming at Resident #19. The ARNP reported an allegation of verbal abuse to the Social Service Director; however, the facility failed to report the allegation to the SSA or complete an abuse investigation.
Resident #10 received and unwelcomed kiss from Resident #9, on [DATE]. There was no documented evidence the incident was investigated by the facility and there was no evidence the facility implemented interventions to prevent re-occurrence and to protect residents from potential abuse.
Continuing: Resident #15 and Resident #16 were in a physical altercation (as defined by the OIG report) and an altercation as identified in the nurses note on [DATE].
Continuing: Resident #15 thrust his/her arm into the back of Resident #16′s wheelchair. The incident was not investigated by the facility as potential abuse towards Resident #16 and no evidence the facility implemented interventions to prevent re-occurrence.
Continuing: Resident #13 made verbally threatening remarks to Resident #14, on [DATE]. Resident #13 was cursing and arguing with Resident #14 then threatened Resident #14 that he/she would stab him/her with a long handled shoe horn. Resident #14 yelled to Resident #13 he/she was going to knock his/her M—– F—— ass out that wheelchair. The incident was not investigated by the facility as potential abuse and no evidence the facility implemented interventions to prevent reoccurrence between Resident #13 and Resident #14 or to protect other residents from potential abuse.
Continuing: Resident #11 threw a bowl of soup that landed on Resident #12, on [DATE]. Social Services documented Resident #11 was angry and continued to be angry in the dining room. Resident #11 was upset with the meal and picked up the soup and threw it at Resident #12 and yelled shut up, when it landed on Resident #12. The staff did not assess Resident #12 for any injury until a skin assessment was completed on [DATE], two (2) days later. The incident was not investigated by the facility and there was no evidence the facility took action to address Resident #11′s physical abuse towards Resident #12.
Continuing: The facility also reported a physical altercation that occurred on [DATE] between Resident #17 and Resident #18. The facility did not complete an investigation to determine a root cause to prevent an altercation from occurring again.
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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