Staff at a Falmouth personal care home did not check on a brain-injured man for nearly three hours on the day he disappeared, according to documents from a state investigation. The man was found dead more than four weeks later.
In addition, the investigation by the Cabinet for Health and Family Services' Office of Inspector General into Larry Joe Lee's August disappearance revealed that Falmouth Nursing Home had no policy to ensure that residents had continuous supervision. And investigators determined "the facility failed to establish effective policies to ensure continuous supervision of residents."
Lee, 32, had a brain injury from a childhood accident, was schizophrenic, bipolar and diabetic. He went missing from the facility on Aug. 4. No one from the home's staff saw Lee or checked on him from 2:30 to 5:15 p.m. that day, according to documents obtained by the Herald-Leader through the Kentucky Open Records Act.
On Sept. 3, Lee's body was found near the banks of the Licking River. Officials said recently that they had not been able to determine his exact cause of death.
The state's investigation had ended by Oct. 19, cabinet spokeswoman Beth Fisher said.
Tracy Winkle, the administrator at Falmouth Nursing Home, did not return a telephone call for comment Wednesday. A company called WE-CARE is listed in state records as the home's owner, according to cabinet officials.
After receiving the findings of the state investigation, facility officials submitted to the state a plan of correction that included training for the staff and new policies to monitor the whereabouts of residents. Facility officials also contracted with a nurse consultant who conducts monthly reviews.
Since Lee's death, advocates and state lawmakers have been questioning whether personal care homes are the appropriate place for people with brain injuries.
Personal care homes provide long-term care for people who do not need full-time nursing care but need some assistance. They provide services to a population that mostly includes the mentally ill and mentally disabled. There are 82 free-standing personal care homes in Kentucky serving more than 3,000 people.
Lee was a ward of the state, a decision that officials had encouraged his family to make so he could get better services. The inspector general's investigation found that Lee's state guardian had made no restrictions about him leaving the facility. He had no history of "elopement," according to the state investigator's review.
The state's investigation also provided more details about the day Lee went missing.
The administrator told state investigators she saw Lee at 1 p.m. Aug. 4 when he walked by her office window. An employee identified in state documents as nurse's aide No. 2 said she saw Lee smoking in a back room at 2 p.m., and he went to his room at 2:30.
Later, an assistant administrator, who was not identified in state records, called Lee to the office to pick up a letter that had arrived for him. (It is unclear from the documents whether Lee was called on an intercom system.)
Lee did not respond to the call, the state documents say.
The assistant administrator said nurse's aide No. 2 told her she saw Lee go into his room and shut the door at 2:30. The nurse's aide said she assumed Lee was asleep and did not go check on him. The assistant administrator said she told a staff member who was starting a new shift that Lee was asleep with the door shut. The documents identify that staff member as nurse's aide No. 1.
Nurse's aide No.1 said "it was assumed" that staff were to check on residents every hour, but she did not check on Lee because the assistant administrator told her he was asleep, according to state documents.
Nurse's aide No.2 said she called for Lee to come and get his medicine at a medication cart at 5:15 p.m., but he never did. When Nurse's aide No. 2 went to Lee's room, he was not there, according to the documents.
On Aug. 5, a Friday, Lee's state guardian called his family and told them Falmouth Nursing Home had reported Larry Joe missing the day before.
Nearly a month later, two bow hunters found Lee's body near the banks of the Licking River. The body was identified using dental records.
The facility received a citation from the Cabinet for Health and Family Services' Office of Inspector General on Sept. 23 alleging that it was not well kept, safe or in good repair.
State Sen. Jimmy Higdon, a Republican from Lee's hometown of Lebanon, said Wednesday that he was "fact-finding" to determine what kind of changes to state law would best prevent similar situations.
In addition to the problems found in Lee's disappearance, state investigators said staff at Falmouth failed to keep residents free from mental abuse because they cursed at and in front of residents, which was prohibited by a facility policy.
Mary Hass, director of advocacy for the Brain Injury Alliance of Kentucky, said state law should be changed so assessments have to be done on every individual before they are placed in a personal care home and again every six months to make sure the staff is equipped to care for them. Training is also important, she said.
"Right now there is no true oversight on training for the staff employed in these facilities," Hass said.