In January 2009, 88-year-old Irene Hendrix was found in a pool of blood at Cambridge Place Nursing Home in Lexington behind a closed door in a room that stored equipment.
Bones in Hendrix's face were broken, there was bleeding in her brain, she had a 4-centimeter laceration on her forehead, a cut on her lip and a swollen eye, according to state documents. Hendrix, who has Alzheimer's, was in a hospital for three weeks and nearly died, according to her daughter.
Nursing home staff told investigators that Hendrix fell, according to state records, but reports from three state agencies contain discrepancies and reach no conclusion about what caused her injuries.
Investigators closed the case without prosecuting it or issuing a Type A citation that indicates a resident's life or safety has been endangered because of violations of state regulations.
Last week, Scott Owens, an attorney representing Hendrix in a 2009 lawsuit against the nursing home, asked Attorney General Jack Conway's office to reopen the investigation. Hendrix's case, Owens said, is an example of an investigation at a Kentucky nursing home that "simply didn't go deep enough."
"There was enough evidence to raise a flag that there was a possibility that she could have been attacked ... . And we know that wasn't investigated at all," Owens said.
Allison Martin, a spokeswoman for Conway, said "a preliminary investigation was done and found no evidence of a criminal act." Martin said the office's investigators received Owens' request to reopen the case and are reviewing it.
Cambridge Place officials have denied any negligence in a court filing, said Paul Dzenitis, an attorney for the nursing home. Dzenitis declined to comment further because of the ongoing litigation.
A recent Herald-Leader investigation found gaps in the state's system for investigating and prosecuting nursing home injuries and deaths. Among other things, police are rarely notified at the time serious injuries occur, the newspaper found.
"I think the police should investigate every incident immediately," said Mary Gullette, Hendrix's daughter.
The state's investigation system, which relies on the attorney general's office, the Cabinet for Health and Family Services' Office of Inspector General and the cabinet's Adult Protective Services branch — is "so dysfunctional that the nursing homes are not held accountable," Gullette said, "and the current laws are not protecting the elderly from abuse and death."
In the Hendrix case, the attorney general's investigator said the cabinet's adult protection worker thought Hendrix's injuries were the result of an accident. The adult protection worker also determined that Hendrix was a victim of caretaker neglect and had been exposed to an extreme safety risk.
The adult protection worker sent her report to the Lexington police department, the attorney general's Office of Medicaid Fraud and Abuse Control and the Office of Inspector General, the agency at the cabinet that inspects nursing homes and investigates complaints about them.
Nursing home staff told investigators from the state agencies that Hendrix went missing on the morning of Jan. 21, 2009, while moving up and down the hall in a special walker with a seat called a Merry Walker.
The information that each investigator reported based on interviews with nursing home staff varied, including the description of the room where Hendrix was found and where she was seen in the facility.
In her report, the adult protection worker called the room where Hendrix was found "an area with storage equipment." The attorney general's investigator found that it was a physical-therapy room "set up similar to a residential room." Office of Inspector General investigators said it was "an empty resident's room."
Reports about other aspects of the incident also differed. The adult protection worker's report said one theory was that Hendrix got the rooms confused and fell over a wheelchair.
Investigators from the Office of the Inspector General said the nurse's aide who reported finding Hendrix said the side of her face was "to the floor" and she was still in the Merry Walker.
Nursing home staff members told the attorney general's investigator that they thought Hendrix's walker caught the door frame or a raised threshold, causing her to land on her face and the walker to fall on top of her.
Owens and Gullette said that to their knowledge, Hendrix received injuries only to her face. Owens said he hopes investigators will look at why she did not have significant injuries elsewhere if the Merry Walker fell on top of her.
Owens said he learned through his investigation that there had been recent resident-on-resident assaults at the nursing home before the Hendrix incident. He said he hopes investigators will re-examine the possibility that another resident, a staff member or a visitor could have attacked Hendrix.
After receiving a report from the adult protection worker, officers with the Lexington Division of Police learned that the attorney general's office was investigating. As is customary, police deferred to the attorney general, said police spokeswoman Sherelle Roberts.
Aside from an investigation into whether a crime was committed, the cabinet's Office of Inspector General looked into whether the facility complied with federal and state regulations.
The report from the inspector general's office said the nursing home's written plan for Hendrix was based on a doctor's orders that Hendrix should have been checked every 30 minutes while she was in the Merry Walker. But several staffers interviewed by state inspectors said they did not know about those orders.
Owens said he thought the inspector general's office should have issued a citation that reflected the seriousness of Hendrix's injuries and the fact that nursing home staff didn't follow orders.
Owens said similar infractions at other nursing homes have resulted in a state Type A citation, which is given when a resident is put in imminent danger or faces substantial risk of death or serious mental or physical harm.
The nursing home off Versailles Road did receive a federal citation. Out of four federal levels of non-compliance, with the fourth being the most severe, the nursing home received a level-three citation in relation to Hendrix's injuries, said cabinet spokeswoman Beth Fisher. The nursing home was required to correct the deficiency, with follow-up inspections.
Gullette, Hendrix's daughter, said she moved her mother after the incident to Bluegrass Care and Rehabilitation Center in Lexington, where Hendrix remains.