The Edmond Sun had a recent article about a 131 page investigative report that supports complaints against a nursing home in Oklahoma. One of the complaints includes a lack of an effective system for investigating and reporting abuse and failure to consult with a resident’s physician when there was an injury. The investigation was triggered by a Sept. 16, 2008, incident at Grace Living Center. On that day, a resident, Lester Pendergraft, allegedly sexually assaulted a 67-year-old resident. Pendergraft has been charged with one count of rape by instrumentation.
A meager $10,000 penalty resulting from the investigation has been proposed by the Centers for Medicare and Medicaid Services.
Documentation showed the victim’s daughter was notified at 8:45 a.m., 1 hour and 35 minutes after the incident occurred at 7:10 a.m. Edmond Police arrived shortly after they were notified, at about 9 a.m. The victim’s doctor was called between 8:15-8:25 a.m., shortly after he arrived at his office.
On Sept. 25, the detective assigned to the case said, “The facility did a poor job of protecting the evidence.” He said facility staff threw away evidence and washed the victim’s bed linens and clothing and Pendergraft’s clothing. Why would the facility do that unless they were trying to cover up what happened?
According to the report, the facility’s staff should immediately notify the director of nurses and the doctor, get the resident out of harm’s way and assess the resident whenthere is an allegation of abuse or neglect. “The resident was not assessed timely after the incident,” the report stated.
The detective said someone in charge said to another officer that he felt “The situation was being blown out of proportion.”
Citizen advocate Wes Bledsoe, founder of A Perfect Cause, an advocacy organization for disability and elder rights, said when he read the report he was “deeply disturbed." Bledsoe said what was most shocking was that the incident happened in the first place, that evidence was destroyed with either intent or by incompetence and that a staff member voiced concern about police blowing the situation out of proportion. Furthermore, there were warning signs before the incident that Pendergraft posed a threat to residents. Pendergraft was entering rooms of residents without reason or explanation who could not call out for help.
According to the report, a certified nurse aide reported before the Sept. 16 incident that she observed Pendergraft touch another resident who was dependent on staff for assistance. The same day, Pendergraft was seen pulling up the shirt of still another resident who was dependent on staff for assistance.