The state Office of the Inspector General has cited a Pembroke nursing home for creating a situation the regulatory agency says allowed a resident to commit suicide.

Pembroke Nursing and Rehabilitation Center was issued a type “A” citation as a result of an inspection by the OIG, a department of the Cabinet for Health and Family Services, following the July 24 death of Betty Miller.

This is the most serious regulatory citation that can be issued, said cabinet spokeswoman Beth Fisher. This citation occurs when there is an “immediate, very serious threat to health and safety,” Fisher said.

In a written statement, Luanne Porter, administrator of the nursing home, said the facility refuted the findings.

Miller, 64, was found in bed with a plastic bag covering her head, according to the citation report and a Christian County Sheriff’s Department report.

The citation alleges the nursing home did not adequately supervise the resident and failed to identify environmental hazards, having previous knowledge about her medical history.

The report states the home admitted the resident with knowledge of numerous drug overdoses in the past and multiple hospitalizations for paranoid schizophrenia.

The home documented on Feb. 8 that the resident was “depressed, had little energy, felt bad about self, and had thoughts regarding being better off dead,” according to the citation report.

On July 24, nursing home personnel checked on Miller at 12:45 a.m., and did not return until 6:45 a.m. At this time Miller was found dead. In a phone interview Friday, Mike Stokes, deputy coroner for Christian County, said he is still waiting for Miller’s autopsy report from the state medical examiner’s office in Louisville.

The OIG report states interviews with Miller’s family revealed a “long history” of discussing committing suicide. Despite the previous history, the notation about her demeanor in February and the family knowledge, the home did not identify risks, environmental hazards or administer the appropriate amount of supervision associated with the resident’s mental condition.

“This failure presented an imminent danger and created a substantial risk that death or serious mental or physical harm to a resident will occur,” the report concludes.

 In the statement she provided to the New Era, Porter wrote, “Our staff followed an appropriate care plan for this resident based on the information the center had at the time. The facility is following the state’s informal dispute resolution process “as we feel strongly that proper care and services were provided to this resident.” 

Porter called the situation “unfortunate” and expressed condolences to Miller’s family and friends. Because of federal privacy laws, she declined to discuss Miller’s care.

After Miller died, Porter noted, the home alerted authorities and cooperated with the state’s investigation.

A complaint spurred the investigation; Fisher said this is common, and could have come from an employee of the home, a family member or someone else. The report states the citation was issued July 27 and needed to be corrected immediately. A state surveyor verified the problem had been corrected on July 28, according to the report.

The citation is the latest in a series of critical findings at the nursing home. In 2009, the Government Accountability Office found the home to be the sixth lowest performing facility in Kentucky. The same year, the Centers for Medicare and Medicaid Services gave the home two out of five stars in a ranking of the quality of care.

As of Aug. 1, two days before the citation was issued, the home was given one out of five stars by the same agency.

After repeated type “A” citations go uncorrected, Fisher said, the OIG can issue fines. In this situation, she did not think a fine had been levied.

Fisher said the citation will show up during annual licensure surveys, and the information is available to anyone that files an open records request.

“We suggest families file open records requests,” Fisher said. “We want that to be a part that residents do when they are searching for long-term care.”

REACH DAVE BOUCHER at 270-887-3262 or

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