The death last month of a Paintsville nursing home resident from injuries suffered in a fall has resulted in a Type A citation — the state's most serious regulatory censure.
A Type A citation from the Cabinet for Health and Family Services' Office of Inspector General indicates that a resident's life or safety has been endangered because of violations of state regulations.
Officials at Mountain Manor of Paintsville, who received the citation Nov. 3, did not return telephone calls seeking comment. The owner of the home is listed as Paintsville Investors. State records show that the managers of Paintsville Investors are HD Fitzpatrick Jr. and Jack Absher.
The resident, whose name and gender were not included in the citation, was admitted to Mountain Manor on Oct. 14, according to the citation.
The citation also alleged:
■ On Oct. 15, the resident was assessed by the staff to be at a high risk for falls, and the staff implemented the use of two raised three-fourths-length side rails on the resident's bed.
■ On Oct. 16, the resident began trying to get out of bed unassisted, "exiting the bed around the side rails." A physician wrote an order for an alarm that would notify staff when the resident got out of bed.
"However, there was no evidence the bed alarm was implemented," the citation said.
According to the resident's medical record and interviews with staff members, residents and a visitor, the resident continued to attempt to get out of bed on Oct. 17, "without evidence the safety of the side rails was assessed, nor any interventions implemented to prevent the resident from falling."
■ On Oct. 18, the resident was found on the floor near the bed. Hospital records, the citation said, showed that the resident suffered broken bones around the eye and six broken ribs.
A physician told state investigators that the resident developed lung complications as a result of the broken ribs and died on Oct. 26 because of complications from the fall.
"... The facility failed to maintain an environment free of accident hazards, as evidenced by the continued use of side rails for a resident who had attempted to exit the bed multiple times, climbing around the side rails," the citation said.
Among 26 Type A citations issued since January 1 and obtained by the Herald-Leader under the Kentucky Open Records law, there were two other cases of deaths and six injuries or situations that required hospital treatment. Two of the citations stemmed from reported sexual abuse.
