It’s been three months since the Communities at Oakwood last had to hear the words “Type A citation,” seemingly putting a period of great turmoil for the massive mental health facility in the rearview mirror.

So it seemed somewhat jarring Monday when a spokesperson for the Cabinet for Health and Family Services announced Oakwood had received just such a citation — and while Steve Shannon, Deputy Commissioner of Mental Health and Mental Retardation, wouldn’t call the newest citation an aberration, it was clear he did not intend for such reports to once again become habit.

“We have to make sure supervisors and staff working with folks at Oakwood know what they’re doing and what the expectations for them are,” stated Shannon.

The citation — Oakwood’s second of the year, according to CHFS spokesperson Vikki Franklin — revolved around a March incident in which, according to the citation report, one Oakwood resident hit another in the head with a shower nozzle while bathing, causing an injury to that client’s head.

“Interview with the staff member assigned to client #64 (the client who allegedly used the shower head as a weapon) revealed that the staff member left client #64 unsupervised in the bathtub to go to another client’s room,” read the report. “He stated that when he returned to the bathroom, client #64 was standing with a shower nozzle in his hand and client #29 (the injured resident) was observed with his forehead bleeding.”

Continued the report, “Further interview with the staff member revealed he was not aware of client #64’s diagnosis of seizures or that the client required direct supervision during bathing.”

That last part is key to Oakwood’s avoidance of future incidents such as this one, according to Shannon.

“We have to make sure that the staff working in the cottages understand what the expectations for them are,” said Shannon. “We want to make sure people (living at Oakwood) are safe and (bath time) can be a time when there is a risk.

“The real issue hangs on that we did not provide the level of supervision we said we would during bathing,” continued Shannon. “It may well be that the (direct care staff member) left this person to attend to another, but that created the opportunity for the individual (to take) the showerhead off and harm another. We reported it and it was not a serious injury, but we didn’t look at it from the perspective of the resident who hit the other, and from his perspective, we didn’t give him enough one-on-one supervision or we could have intervened and prevented (the incident).”

In a Monday press release, the Cabinet for Health and Family Services said they along with Liberty Health-care, the Pennsylvania-based private firm entrusted with management duties of Oakwood, have “taken additional steps to ensure safe conditions at the Commun-ities at Oakwood” following the discovery of the incident.

“The management and staff at Oakwood are committed to continuing their work to protect the health, safety and welfare of the residents at Oakwood,” acting CHFS undersecretary William D. Hacker, M.D., was quoted as saying in the press release. “Despite the noted progress, (Oakwood) still faces substantial challenges in the days and weeks ahead to make the improvements that both the Cabinet and the federal government feel are necessary to improve the quality of life for the residents.

After a string of 15 citations dating back to early 2005, the latest having come on Feb. 14, things at Oakwood seemed to stabilize. A hiring search was conducted to replace many staff members lost to attrition and to add further staffing help, and Gov. Ernie Fletcher even told the Commonwealth Journal in April that Oakwood, currently overseeing only 262 mentally challenged individuals — down from over 300 at the start of the recent turmoil — had “turned the corner.”

According to Shannon, that recent tranquility was due to the efforts made in recent months by both state officials and the private management company to correct the problems Oakwood was facing.

“We’ve hired a lot more people — we’ve really addressed the issue of sufficient direct care staff,” said Shannon. “Liberty (Healthcare) has really made that happen. Staff have been less tired and have done a good job.

“Now the challenge before Oakwood is to turn those folks into very competent direct care professionals,” added Shannon. “That requires training (and) sufficient numbers. That will contribute greatly to the safety of those at Oakwood, which has always been our primary focus.”

Recommended for you