This history of abuse of the men and women who live at Oakwood covers the period from late 2001 to the present. It will be updated as needed. We begin with the most recent incident and work our way back.

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July 20, 2007

The Office of the Inspector General issued a Type A citation. On June 17, 2007, second shift staff discovered that a resident had a reddened imprint to the left cheekbone that had the appearance of a shoe print pattern. The resident had severe mental retardation, autism, and PICA. Oakwood's investigation of the incident could not determine how the injury happened. Oakwood failed to investigate why first shift staff failed to report the incident. The resident had four additional injuries over a seven day period. Only one of those injuries was investigated by Oakwood which could not determine how the injury happened. The OIG asked to view a surveillance tape which revealed a staff person hitting the resident and dragging him across the floor to his room. Only after OIG requested the tape did Oakwood administrative staff view the tape. Oakwood's failure to view the tape in its investigation permitted the staff person to continue working with the resident and other residents for 18 days. The facility's failure to ensure clients were protected from abuse presented an imminent danger and created substantial risk that death or serious physical harm could occur.

July 3, 2007

The Commonwealth Journal reported that Bluegrass CEO Joseph Toy planned to appeal the Type A citation issued by the Office of the Inspector General on June 6 and the Type A citation issued by OIG on June 28. Mr. Toy indicated that the June 6 incident "did not warrant so harsh a penalty." He was quoted as saying that the June 28 incident was even "weaker than the other one." 

June 28, 2007

The Office of the Inspector General issued a Type A citation. On April 20, 2007 a resident with a history of past abuse had red ligature marks to his neck and on June 5, 2007 he had redness and bruising to his nose and a reddened area on his left arm. He alleged that staff had abused him on both occasions. Oakwood investigated and determined that staff had not caused the injuries. They did not determine how the injuries had occurred even though the resident was supposed to be on constant supervision (a staff person must be able to see the resident at all times and in all settings). OIG determined that Oakwood's failure to ensure that the resident received the necessary care and services to prevent mistreatment, neglect, and/or abuse presented an imminent danger and created substantial risk that death or serious physical harm could occur.

June 6, 2007

The Office of the Inspector General issued a Type A citation. On May 14, 2007 a resident with a history of choking was returning to Oakwood by van from a medical appointment. Staff bought the resident a hamburger and a drink despite eating precautions that were outlined in the resident's plan of care. The resident swallowed a large amount of hamburger, choked, became non-responsive and turned "blue." Patrons of the restaurant where the incident occurred witnessed the resident choking and staff attempting CPR called 911. Paramedics intubated the resident in the parking lot of a restaurant and transported him to the emergency room. The resident was admitted to the intensive care unit and required mechanical ventilator support. The resident was not discharged from the hospital until June 17. The OIG found that Oakwood's failure to follow the planned eating precautions to prevent choking presented an imminent danger and created substantial risk that death or serious harm could occur.

December 5, 2006

The a nine-member task-force established by the Cabinet Secretary on June 19, 2006 to develop recommendations to help guide the Cabinet's short-term and long-term planning for Oakwood was disbanded.

November 1, 2006

Bluegrass Mental Health Mental Retardation Board took over management of Oakwood. Staff no longer will be state employees. They will become Bluegrass Mental Health Mental Retardation Board employees.

October 19, 2006

The Kentucky Auditor of Public Accounts released a report, Assessment of Kentucky's Privatization Efforts," which included a case study of Oakwood. The Auditor found that between 2003 and 2006 total expenditures had increased 30% while the number of residents decreased 28%. During that time, the cost per resident rose 82%. In December 2005, 29 private contracts worth $17 million were in place at Oakwood. By May 2006 the number of contracts had grown to 36 at a cost of $22 million. As the spending on outside contracts rose, serious Type A citations increased dramatically.

The Auditor pointed out that between August 2005 and February 2006 there were six different individuals acting as the facility director of Oakwood.

September 21, 2005

The Office of the Inspector General issued a Type A citation . On June 25, 2006 a resident with a history of eating inedible things, who was the subject of at least two previous Type A citations, swallowed a pencil sharpener. Even though Oakwood was aware of the potential danger to this resident, it failed to make staff aware of the behavior and failed to train staff in how to deal with the behavior. After an internal investigation, Oakwood disciplined the direct care staff for not supervising the resident but failed to consider that the incident occurred due to the facility's failure to train the staff on the resident's individualized plan.

On July 7, 2006 OIG investigators toured the resident's bedroom and found potentially harmful items that could be swallowed. The Clinical Services Director was notified. On September 20, 2006 OIG reviewed training records. Between September 1-14, 13 staff had been assigned to work with the resident over 26 different shifts. None of the staff had been trained on preventing further incidents of swallowing potentially harmful objects by the resident. OIG concluded that Oakwood continued to place the resident in imminent danger and at substantial risk of serious physical harm.

September 12, 2006

The Office of the Inspector General issued a Type A citation. On July 4, 2006, a resdent with a long history of self-injurious behavior began hitting his head. He had two episodes of self abuse very early on the morning of July 4. A positive behavior support plan had been developed on April 4 detailing what actions staff should take to try to prevent the resident from abusing himself. Part of the plan included contacting the supervisor, a nurse, and the interdisciplinary team leader if the staff was not successful in stopping the self abuse. OIG found that staff had not been trained, none of the appropriate staff was notified on July 4 of the resident's continuing self abuse, and the supervisor was not aware that the staff had not been trained.

OIG investigators were given different explanations for exactly what happened. One staff member said that during the second episode of self abuse, the resident ran out of the bathroom into his bedroom. As the staff member attempted to "block" the client, he jumped back and his legs hit the bed causing him to fall on the bed. Staff claimed that the resident "grabbed me and my knee went between his legs on the mattress." Staff claimed that the resident did not show any signs of pain. The resident used the bathroom at 5:35 a.m. and again at 6 a.m. At that time, staff noticed swelling, stating that the "Scrotal region very swollen, very noticeable, reddish purple."

The resident had to be taken to the local hospital and from there to the UK Medical Center in Lexington. Due to the severity of the injury, the resident's testicle had to be surgically removed. The two staff involved in the incident were not removed from direct care but continued to provide care to the resident. One staff person accompanied the resident to the hospital. The two staff were later fired by Liberty, which is the contractor currently managing Oakwood.

The OIG noted that Oakwood appointed a Client Protection Director on April 9, 2006 to oversee facility investigations after receiving multiple citations for failure to provide a safe environment for residents. Despite that effort, Oakwood continued to fail to identify the root cause of client incidents. Oakwood received seven more Type A citations after April 9, 2006 relating to failure to provide a safe environment for residents, failure to thoroughly investigate incidents and the lack of staff training.

September 12, 2006

The state negotiated a memorandum of understanding with Bluegrass Mental Health Mental Retardation Board to run Oakwood starting November 1, 2006 for $56,750,000. Between September 12 and November 1, Bluegrass will transition staff from the state merit system and contracts with various entities to Bluegrass and will be reimbursed for direct personnel costs.

August 31, 2006

The U.S. Department of Justice and the state entered into a five-year settlement agreement regarding civil rights violations at the Communities at Oakwood. The settlement agreement replaced a 2004 settlement between DOJ and the state. DOJ reviewed Oakwood after reaching the 2004 settlement and found that numerous ongoing civil rights violations continued. In a press release DOJ stated, "The facility also received 22 citations in 2005 and 2006 from the Commonwealth's own Office of Inspector General for the Cabinet for Health and Family Services, including preventable deaths, sexual abuse, and failure to adequately address residents' maladaptive behaviors. Furthermore, Commonwealth prosecutors have criminally charged numerous Oakwood staff for abuse of residents. Under the settlement, the state will implement a remedial plan to correct all of the violations.

August 20, 2006

The Office of the Inspector General issued a Type A citation. On June 27, 2006 a resident jumped out of bed and said, "I told you I'd do it again and I did." The resident had used a nail to give himself 14 cuts on his right and left forearms. This resident had been the subject of three previous Type A citations for hurting himself with sharp objects (razor, broken CD, staples) on April 17, November 3, and November 18, 2005. OIG found that although Oakwood was aware of the resident's history of hurting himself with sharp objects and had received three previous Type A citations for failure to protect the resident from self-injury, Oakwood continued to fail to address the substantial risk of serious physical harm or death to this resident. Inspectors from the OIG found that the Oakwood had written a positive behavior support plan for the resident. OIG also found that none of the four staff or supervisor working with the resident on June 27 had received any training in the plan. None of the four nurses who routinely worked with the resident had been trained about implementing the plan. Management was not aware that staff had not been trained and there was confusion among management about who was ultimately responsible for ensuring the behavior plan was being implemented and was working. OIG concluded that Oakwood's on-going systemic failures continued to create an immediate and serious threat to the health, safety and welfare of the resident.

August 9, 2006

The state received a letter from The Center for Medicaid and Medicare Services giving formal notice of a 30-day review, beginning September 22, 2006 , to determine whether federal financial funding would continue to be provided. "[CMS] is now in receipt of 21 Type A citations . . . from the Kentucky Inspector General's office that continue to identify immediate and serious threats to the health and safety of clients at the Oakwood Community ICF/MR...This letter follows a large number of conference calls and other communications we have had regarding the safety and quality of care experienced by clients of the Oakwood Community ICF/MR... [T]he continuing, recent, and serious nature of many of the findings convinces us that much more vigorous and effective action is required on behalf of all clients at Oakwood."

August 2, 2006

The Office of the Inspector General issued a Type A citation. On June 6, a resident was struck with a broom by staff (two of the three staff identified as perpetrators were later arrested). The resident, who had been the subject of a Type A citation on __________, had bruising and raised reddened areas to his upper back, back of his left forearm, right inner leg, and left upper buttock. A staff member later reported that she did not witness the abuse but she heard at least two smacks and heard the resident yelling at least three of four times.

One staff member in the cottage told the OIG investigators that she had been afraid to report the abuse because "I was threatened several times." She told investigators that one of the perpetrators threatened that if she reported the abuse, they would come to her house and kill her. Two residents in the cottage reported that the abuse had happened before. One resident said that he was afraid of the staff. Another resident said that the resident who was hit with a broom "gets in trouble for stealing pop" and "that it takes three women to give him a 'whippin.' " This resident told investigators that the abusive staff, whom he named, told him "not to tell."

The abuse of this resident had been reported to the facility investigator while it was happening by another resident who lived in the cottage. The investigator did not immediately do anything to ensure the safety of the residents in that cottage. He did not arrive at the cottage until 15 minutes after he received the report. He told investigators that he was not responsible for going to the cottage to protect residents from abuse.

OIG staff also found that numerous incidents of abuse had been reported from this cottage but had not been investigated thoroughly by facility staff. OIG staff reviewed incidents dated February 13, March 26, April 4, April 11 and April 12. The Oakwood investigations concluded that each of these allegations of abuse was unsubstantiated. OIG investigators found that the investigators had failed to interview other residents and staff who may have witnessed the alleged abuse, only inspected a resident's head and failed to consider all of the other injuries the resident had, only interviewed the alleged perpetrators of the abuse, and failed to remove alleged perpetrators from direct care of residents. OIG concluded that the facilities failure and inability to correct the failures continued to place all clients in imminent danger and substantial risk of serious physical harm.

July 14, 2006

A former Oakwood employee pleaded guilty to a 2003 attack on a resident. The former employee admitted dragging the resident across the floor, striking her in the head with a shoe, and shoving the resident's head into a wall.

July 14, 2006

The Office of the Inspector General issued a Type A citation. A resident was verbally and physically abused on a fishing trip on May 9, 2006. On the return trip, staff called Oakwood and reported that the resident had harmed himself. An Oakwood physician found that the resident had bruising to the left eye, edema, abrasions, deformity and bruising to his nose, mild bleeding from the nose and abrasions to his right knee and elbow. The resident was taken to the emergency room where x-ray revealed that his nose had been broken. OIG inspectors determined that the resident had been subjected to abuse on previous occasions, including being held down in his bedroom and choked with a towel until he turned purple and being locked in his room

The resident lived in cottage 103 which the facility and the Governing Body Committee were concerned about because of "a lot" of alleged abuse and a high number of injuries to residents prior to May 9. Neither the facility nor the governing committee took any action to reduce the risk of harm or abuse to the residents. The OIG found that allegations of abuse of this resident as well as allegations involving other residents in cottage 103 had not been investigated adequately by the facility and had not been substantiated.

On the day of the fishing trip, staff took several residents to a secluded location on Lake Cumberland 36 miles from Oakwood with a steep grade from the parking area and deep water immediately off the shoreline. Three of the staff members on the trip previously had been identified as alleged perpetrators of abuse of residents in cottage 103.

One staff member kicked the resident as he was climbing back up the hill and told the resident, "Get up the hill, you f______ retard." The same staff person later told the resident, "Get in the f______ van, you retard." One staff member sat on the resident while three others hit and kicked him in the stomach, head, and legs. When the resident began to cry, the staff member sitting on him got up and punched the resident in the stomach six or seven times. When told to "Get up, we're leaving," the client refused. A staff member kicked him in the nose. A witness reported hearing a loud "pop" and observed the resident's nose bleeding "a lot." Staff members cleaned up the blood with a blanket and one said, "We have to get rid of the blanket, it's evidence." After returning to Oakwood, three of the staff continued to abuse the resident by pushing on his broken nose to cause additional pain.

The staff who perpetrated the abuse threatened the other staff into reporting the incident as the resident harming himself. On June 1, an anonymous caller alleged that the resident's injuries were the result of abuse, contrary to what was originally reported. The four alleged perpetrators of the abuse of this resident were arrested on June 19. Liberty Health Care has been fined $10,000 for the Type A citation.

July 13, 2006

The state approved a four-month contract with Liberty Health Care to continue to manage Oakwood. The contract was for $8.8 million.

July 2, 2006

The Office of the Inspector General issued a Type A citation. Oakwood was cited for failing to properly supervise a resident during an off-campus trip on April 24. 2006. The resident, who is blind and has a history of seizures, wore a protective head helmet and needed one-to-one supervision while outside the home. Three hours after she returned from the trip, staff discovered bright red bleeding to the back of her head with a six centimeter deep laceration. Staff could not explain how the injury happened. A physician and two nurses examined the resident and stated that the injury had been caused by a sharp, hard, direct blow to the head which had penetrated the ventilation areas in the protective helmet. The resident was transferred to the emergency room and received surgical staples to the wound. The OIG found that there had not been sufficient staff on the trip and that none of the staff had been trained about the resident required level of supervision. The OIG found that the Oakwood's failures to ensure appropriate supervision, to ensure that staff were trained, and to protect clients from harm, placed the resident in imminent danger and substantial risk of serious physical harm.

The state's contract with Liberty Health stated that Liberty would be fined $10,000 for each type A citation received six months following the beginning of the contract. Liberty was not fined for the Type A issued by the OIG on July 2, 2006 because the actual incident that led to the Type A citation occurred within six months of Liberty's contract which began on November 1, 2005.

June 27, 2006

Four staff members were arrested for allegedly assaulting an Oakwood resident on May 9 and June 6, 2006 with a broomstick. The Kentucky Bureau of Investigation, a unit of the attorney general's office, received an anonymous tip on June 1, 2006. (This resident was injured previously and was the subject of a Type A citation issued on February 2, 2006.)

June 23, 2006

Jacqueline Bouyea of Liberty Healthcare was appointed director of Oakwood following the resignation of Bob Ritz due to health issues.

June 19, 2006

Four staff members were arrested for allegedly assaulting an Oakwood resident on May 9, 2006. The resident had multiple cuts and bruises and a broken nose. Staff reported that the resident had injured himself. The Attorney General's Office began investigating the incident on June 9.

June 19, 2006

Secretary Mark Birdwhistell appointed a nine-member task-force to develop recommendations to help guide the Cabinet's short-term and long-term planning for Oakwood. Six members were from the HB 144 Commission on Services and Supports to Individuals with Mental Retardation and Developmental Disabilities. Three additional members were appointed: Donna Burton, an Oakwood employee; Gary Latham of Hopkinsville , the parent of an Oakwood resident and a former hospital administrator, and Tim Veno of Louisville , the president of the Kentucky Association of Homes and Services for the Aging and a former Kentucky Inspector General.

June 16, 2006

Governor Ernie Fletcher requested an immediate investigation of abuse allegations at Oakwood by the Kentucky State Police. He urged the State Police to collaborate with the Office of the Attorney General. The Governor had been briefed by his Cabinet for Health and Family Services Secretary and by the Inspector General about a "variety of extremely serious and troubling allegations of physical and mental abuse of Oakwood residents."

May 31, 2006

The Office of the Inspector General issued a Type A citation. Between March 9 and April 13, 2006 a resident experienced an increase in aggressive behaviors toward other residents that resulted in harm. The aggressive behaviors included: hitting a resident in the head with a shower nozzle which resulted in a cut (that incident resulted in its own Type A citation on May 12, 2006), hitting a resident in the face with a dustpan that resulted in a cut, hitting a resident in the nose which caused a nose bleed and an open area on the nose, biting this same resident's ear, and six hours later stabbing this resident in the eye with a pen. There were approximately 20 additional incidents in March and April that had the potential to cause injury to other residents. (The OIG investigated this series of incidents only after P&A made a formal complaint on behalf of one of its clients. Oakwood did not report any of the incidents.)

The resident's interdisciplinary team knew that his aggressive behaviors toward other residents happened during "down times" or when the client had no planned activities in which to participate. Despite this knowledge, the resident had only 30 minutes of planned activity every day. After completing his 30 minute task, he was finished for the day and returned to his home. The OIG found that Oakwood had knowledge that there was a high probability that the resident would harm other residents yet failed to find something meaningful for the resident to do during the day. The OIG concluded that the failures posed an immediate and serious threat to the health and safety of facility clients.

May 22, 2006

The Secretary of the Cabinet for Health and Family Services issued an Administrative Order directing the Commissioner of the Department for Mental Health and Mental Retardation to:

1. Conduct a Root Cause Analysis investigation and prepare a report within 15 days of citations received since January 1, 2006,
2. Prepare a Vision Plan for Oakwood's Short-term and Long-term Future and report within 45 days,
3. Conduct a Clinical and Operational Assessment and report within 15 days of Subdividing Oakwood into Multiple Licenses

May 19, 2006

The Office of the Inspector General issued a Type A citation. On April 3, 2006 , a resident was admitted to the hospital with dehydration and severe hypernatremia. (1) While in the hospital, foreign material was found in the resident's stomach that required surgery. Two disposable gloves were removed from the resident's stomach. The pathologist stated that the gloves had been there "awhile." The resident had a history of pica (desire to eat anything) (2) , especially disposable gloves. All disposable gloves were to be secured and accounted for after being used by staff. The shift supervisor was required to confirm that gloves had been properly discarded.

The procedures were not followed on 13 days in March and the count was short on 7 shifts in March. The shift supervisor procedure was not followed on 15 shifts in March. On March 5, a supervisor signed that all gloves had been accounted for when the count was actually two short. The OIG found that Oakwood had failed to identify the problem with the glove accountability procedures and failed to identify the overall lack of training on pica precautions specific to the resident. The OIG found that staff was not aware of the procedures and was not aware of the client's specific pica behaviors. The OIG concluded that Oakwood's continued failures placed clients in imminent danger of serious physical harm.

May 12, 2006

The Office of the Inspector General issued a Type A citation. On March 9, 2006 a resident, who required direct supervision while bathing due to a history of seizures, was left unsupervised in the bath tub. When staff returned, the resident had a shower nozzle in his hand and another resident was bleeding from his forehead. The staff person was not aware of the resident's history of seizures or that he required direct supervision during bathing. The incident was not investigated or reported to the OIG. The OIG discovered the incident two months later while reviewing records and prompted staff to report the incident as possible neglect. The OIG concluded that the facility failed to have an effective system in place to ensure that incidents of neglect are identified and investigated. The OIG concluded that Oakwood's failure to properly identify and investigate the lack of adequate supervision during bathing presented an immediate and serious threat to the health and safety of the clients of the facility.

The state's contract with Liberty Health stated that Liberty would be fined $10,000 for each type A citation received six months following the beginning of the contract. Liberty was not fined for the Type A issued by the OIG on May 12, 2006 because the actual incident that led to the Type A citation occurred within six months of Liberty's contract which began on November 1, 2005.

February 14, 2006

The Office of the Inspector General issued a Type A citation. A resident who had blood in his stomach had to have emergency surgery. It was discovered that he had a perforated bowel. Another resident had kicked him on February 1, 2006 (the day of the Governor's visit to Oakwood). The OIG concluded that the injury was life threatening.

The resident who did the kicking had a life long history of aggressive behavior according to an Oakwood psychiatrist. His aggressive behaviors increased from none in November 2005 to 19 in December, 19 in January, and 53 over a one week period February 1 through 7, 2006. A direct care staff reported to OIG that she had never seen the resident display such aggressive behaviors before and that the interventions staff were to use were not effective.

The resident's treatment team met on October 21, November 16, November 18 and February 3 (two days after the incident) but failed to note the increase in aggressive behaviors and failed to address the dramatic increase in behaviors. The OIG concluded that the facility's numerous failures presented an immediate and serious threat to the health and safety of the clients of the facility.

February 2, 2006

The Office of the Inspector General issued a Type A citation. A resident was injured twice by suspected staff abuse and by another resident. On January 1, a resident was found with scratches, scrapes, bruises and imprints on his back and shoulders of a grid type pattern consistent with physical abuse. The resident was injured after he kicked a female staff member. The staff member called her boyfriend, also a staff person at Oakwood, who left his assigned work area to go to the cottage where his girlfriend was working. The resident was left in the care of the boyfriend for about 45 minutes. After the resident's injuries were discovered, cottage staff reported that they witnessed the female staff member talking on a cell phone and was overheard calling someone "Baby" and telling that person to change his shoes prior to being interviewed about the resident's injuries.

On January 9, the resident was moved to a cottage he previously had been moved from due to receiving injuries from aggressive residents. Within three hours of being moved, the resident was hit in the head and pushed into a wooden cabinet by another resident. The resident had to obtain treatment in the emergency room due to his injury. The OIG found that the facility failed to provide the required level of supervision and failed to ensure the proper staffing deployment. OIG found that Oakwood's failures posed an immediate and serious threat to the health and safety of all clients.

February 1, 2006

Governor Fletcher visited Oakwood. Bob Ritz officially took over as Facility Director.

January 27, 2006

The Office of the Inspector General issued a Type A citation. A resident with a history of running away, left Oakwood on Friday, January 13 with an unknown female and was absent for three days. On Monday, January 16, the resident called Oakwood and asked for a ride back to the facility. While absent from Oakwood, the resident consumed alcohol and engaged in sexual intercourse with at least one individual. The OIG found that Oakwood failed to ensure that the person picking the resident up and assuming responsibility for him was known to the facility. The resident's state guardian had approved a home visit contingent on facility staff speaking to the resident's sister and verifying that she was aware of and prepared for her brother's home visit. Two home/direct care staff informed the resident's social worker, supervisor, and home coordinator that the female visitor was not his sister. OIG also found that the guard at the information booth failed to document the arrival of the unknown female, her vehicle information, the purpose of her visit, and her time in and out. Based on its findings, the OIG found that Oakwood placed the resident in imminent danger of serious physical harm.

January 2006

The Cabinet for Health and Family Services announces a new director at Oakwood, Mr. Robert Ritz.

December 29, 2005

The Office of the Inspector General issued a Type A citation. A resident, who was the subject of substantiated abuse on October 14 (dragged across the floor and kicked by a staff person) and of a Type A citation on November 18, 2005 (self injury resulting in amputation of big toe), had second degree burns on his chest from hot coffee. The resident was supposed to be supervised at all times and kept within 10 feet of a staff person. A physician determined that the burns had occurred 24-48 hours before they were reported. Although the resident had a history of pouring coffee on his shirt, his behavior support plan did not include safety precautions for coffee. On the day that the burns occurred, a staff person had been pulled from another cottage to provide intense supervision to the resident. The staff person indicated that he was not aware of all of the resident's care needs. The OIG concluded that Oakwood's failure to provide adequate supervision and failure to ensure that the resident was protected from further harm or abuse, posed an immediate and serious threat to the health and safety of the resident.

December 22, 2005

The Office of the Inspector General issued a Type A citation. The OIG had issued a previous Type A citation concerning this resident on November 18, 2005. The resident, who had a history of ingesting foreign objects and fluids, had a behavior plan in place to guard against the behavior, including scanning the environment for items that the resident could ingest. On December 2, the resident swallowed a rock while working at the Oakwood greenhouse. The staff person, who was providing direct supervision to the resident, stated that he was never instructed to implement the precautions in the behavior plan. The entire floor of the greenhouse was covered with loose rocks.

When told that the resident had swallowed a rock, an Oakwood physician instructed staff to strain the resident's stool for seven days. Records revealed that the resident had checked her own stool several times on two different days. The facility failed to consider the potential for the resident to ingest the rock, feces, or the latex gloves she was using.

On December 8, OIG staff surveyed the resident's bedroom. They found potentially harmful items that she could swallow, including small plastic bears, staples, and small plastic clips. Records indicated that staff had conducted sweeps of her bedroom but failed to identify the items she could swallow. The OIG found that the facility's failure to protect the resident by maintaining a safe environment posed an immediate and serious threat to her health and safety.

December 10, 2005

The Office of the Inspector General issued a Type A citation. One resident with a history of slapping and scratching herself was allowed to hit her face 57 times in one hour. Records for this resident revealed 25 self-inflicted wounds in the month of November 2005 and two episodes of self-abuse in December. Staff was unaware of the planned behavior supports that had been developed for this resident in September 2004 to prevent reoccurring injuries. A medical assessment completed on December 5, 2005 documented numerous injuries and wounds to all parts of her body.

A second resident had a history of abusive behaviors that included hurting other residents and staff. A behavior plan had been developed for this resident in February 2005. On two occasions, OIG observed this resident being aggressive toward other clients 9 times and staff 5 times. The resident's record revealed that he had been physically aggressive toward other residents 26 times in November and December. A psychiatry progress note dated December 2, 2005 revealed that it was crucial for him to be involved in daily activities. OIG observed the resident for 5 1/2 hours on two occasions and reported that the resident was not involved in any activity or active treatment program. Staff was not aware of the behavior supports that had been developed.

November 22, 2005

A Pulaski County grand jury indicted a former Oakwood employee, charging her with seven counts of abuse for slapping, kicking, hitting and punching four male residents earlier in the year.

November 18, 2005

The Office of the Inspector General issued a Type A citation. The resident who was the subject of Type A citations on April 17 and November 3 was able to injure himself yet again by obtaining a staple and using it to cut into the scars on his left leg. This occurred after a sweep was made of his room to assure that there were no sharp objects; the investigator noted that during the sweep, a staff binder containing papers with staples was present in the room.

In another incident, a resident with a long history of throwing and flipping heavy furniture sustained an injury to his right great toe which was subsequently reinjured. This led to complications, requiring the amputation of that toe. Despite having an extensive history, no plan was ever put in place to evaluate safety risks or provide interventions.

November 3, 2005

The Office of Inspector General issued two Type A Citations. In the first, a resident who had a history of eating non-food items and a plan to monitor his environment for small items and harmful fluids, was assigned to work off campus removing staples from documents. He ate some staples which was confirmed by two x-rays. This is the same resident who injured himself earlier in the year, leading to the Type A Citation on April 17, 2005.

In the other, a resident who had a history of breaking CDs and using them to injure himself and who had a plan to carefully supervise and monitor any CD usage, was allowed to listen to a CD unmonitored and unsupervised. He broke the CD and used it to cut himself on the legs and wrist. While the investigation was going on, the investigator noticed another resident banging his head with a garbage can lid and against the wall and floor causing him to have abrasions over the left eye, forehead and face. Despite having received daily injuries for the two previous weeks, the resident’s level of supervision had not been reassessed to see if he needed more supervision.

November 1, 2005

The state entered into a contract with Liberty Healthcare, Inc. to manage Oakwood. The cost of the contract is over $9 million for eight months.

October 21, 2005

The Office of Inspector General issued a Type A Citation because a resident who was a known sexual perpetrator was allowed unsupervised around other residents.

October 14, 2005

An Oakwood employee was charged with assaultfor allegedly dragging a resident across the floor, kicking him in the back, and causing him to hit his head on a cabinet door.

September 21, 2005

An Oakwood employee was charged with abuse for allegedly hitting a resident with his fists.

September 17, 2005

The Office of Inspector General issued a Type A Citation because Oakwood did not report suspected sexual abuse of a resident who was left unsupervised at an off campus worksite. The individual stated that he had been inappropriately touched. Besides not reporting the incident as required, Oakwood returned the resident to the worksite.

As a result of this and the prior citations, CMS issued a notice to CHFS that Medicaid funding could no longer be used at Oakwood as of October 14, 2005. CHFS appealed the termination and the timeline was extended.

August 24, 2005

The Office of Inspector General issued a Type A Citation to Oakwood because a resident with a history of seizures was left alone in the bathtub, had a seizure, and drowned.

July 2005

The four Communities of Oakwood were consolidated into one facility with one license.

April 17, 2005

The Office of Inspector General issued a Type A Citation to Oakwood because an individual known for injuring himself with sharp objects was able to obtain a sharp object on four separate occasions and cut himself. One of the cuts was serious enough to require an emergency room visit. Some staff who were supposed to be supervising were pulled from other cottages and did not know his history, the required level of supervision, or the behavioral intervention plan which included recognizing precursor behaviors, keeping sharp objects accounted for and under lock, and providing hourly visual sweeps of his living area.

March 18, 2005

The Office of Inspector General issued a Type A Citation to Oakwood because numerous residents had injured themselves. One resident had numerous bruises all over her body, a number of which appeared to be finger and fingertip prints. In addition, staff had allowed one resident to pace around the cottage for more than an hour with obviously wet pants caused by incontinence. The Inspector General found there were not enough staff supervising the residents and the staff that who were present were not knowledgeable about the specific behaviors of the residents or the behavioral intervention plans they needed.

March 4, 2005

The Kentucky Office of Inspector General issued a Type A Citation to Oakwood because a resident who was at known risk for choking hazards and who had a history of choking, choked to death on a hot dog.

September 21, 2004

A Memorandum of Understanding was signed between the US Department of Justice Civil Rights Division and CHFS. Kentucky agreed to a Strategic Action Plan to address and improve the problems identified in the Department of Justice's November 2002 findings.

May 2004

Oakwood was divided into four facilities, the Communities of Oakwood, with four separate licenses.

2000- 2003

The state entered into a contract with The Columbus Organization to address problems at Oakwood.

November 7, 2002

The US Department of Justice’s Civil Rights Division began an investigation under the Civil Rights of Institutionalized Persons Act after performing some on-site reviews in 2001. Some of the findings of the investigation were that

Oakwood did not protect its residents from harm due to abuse, neglect, and mistreatment

Persons with developmental disabilities received inadequate care from Oakwood, including inadequate behavior and support plans

Oakwood did not provide adequate and appropriate medical treatment

Oakwood’s nursing and direct care staff training programs did not protect its residents from harm and were a major contributing factor to the inadequate nursing care provided

Oakwood did not provide residents with individual meal management plans that would address their nutritional and meal safety needs

Oakwood did not accommodate persons who wanted to live in the community, in violation of Kentucky's obligations under Title II of the Americans with Disabilities Act

November 2001

Protection and Advocacy completed a yearlong investigation concluding that

Men and women at Oakwood continued to experience abuse and neglect.

Men and women living at Oakwood did not receive the active treatment that they needed

Some of the men and women living at Oakwood were unnecessarily segregated due to their disability and were perhaps experiencing discrimination by not being placed in the community

 

Footnotes

The normal concentration of sodium in the blood plasma is 136-145 mM. Hypernatremia is defined as a serum sodium level over 145 mM. Severe hypernatremia, with serum sodium above 152 mM, can result in seizures and death. (back)

OIG issued a Type A citation in December 2001 after this same resident vomited up "a hardened black ball." It appeared to be a glove that most likely had been in his stomach for "an indefinite period of time." The plastic glove had to be surgically removed. (back)