SMITHFIELD – Workers at the Hebert Nursing Home have told health authorities and police that they witnessed, and reported in vain many times, what they consider a disturbing pattern of long-term abuse, with sexual overtones, of a mentally impaired resident.
The Valley Breeze & Observer has obtained reports from government health agencies and Smithfield police indicating that the resident – an 89-year-old woman – for months was subjected to digital penetration of her private parts, and other indignities, by her two daughters.
According to a summary report provided the newspaper, the U.S. Centers for Medicare and Medicaid Services, in cooperation with the State Department of Health, concluded that the nursing home was aware of the concerns but still “neglected to conduct any investigations and allowed the daughters to visit their mother twice daily without ever assessing or monitoring these visits in order to determine the validity of these allegations reported by staff.”
The federal agency last month put the nursing home on notice that as of Feb. 1 it would lose its status as a Medicare and Medicaid provider, but last week withdrew the threat when the 133-bed facility on Log Road reported taking corrective measures. It was also fining the home $5,500 a day.
The Valley Breeze & Observer reported on Jan. 26 that state and federal agencies were investigating alleged violations at the home, the nature of which were withheld at the time, but which were said to have put patients in “immediate jeopardy.”
Now The Breeze & Observer has learned that a long-time psychiatric nurse and two certified nursing assistants gave statements to the police Nov. 30 and Dec. 1 in which they said they saw, and reported to superiors, vaginal and anal penetrations on multiple occasions, and at times saw the daughters with their heads underneath the woman’s blankets near her genital area.
They said the daughters always explained that they were checking on their mother’s incontinency, but the nurse, Jeannine Peterson, of Smithfield, told police that when she observed one of the daughters putting her hand inside the mother’s briefs, “I believe she was doing it for her own sexual gratification …”
According to the report, briefs used at Hebert’s show a blue line if they are wet and there is no need to check a patient manually.
Peterson told police that she is a board-certified psychiatric nurse with 35 years’ experience, and that she “has never seen or heard of any behavior coming close” to the way the two sisters “have been allowed to treat their mother at Hebert’s.”
She said she started working at the nursing home last June and had been fruitlessly reporting on the alleged mistreatments ever since.
According to the investigation summary, the sisters were also seen taking food away from their mother even though she was losing weight, and the staff also observed bruises that looked like pinch marks or twists, which did not recur after the home barred the sisters from the facility Dec. 1, a day after police became involved.
The nursing home’s administrator, Alan J. Barroso, said it would be inappropriate for him to comment immediately on the situation because of the investigation. He said it’s uncertain how the sisters’ visitation requests will be handled going forward but that they are still barred from the facility.
Staffers say the sisters, on many previous visits, paid obsessive attention to their mother’s genitals, checking them, according to Peterson, “probably three to four times an hour” and pushing on the woman’s bladder to make her urinate.
She said many times at the nursing station she would hear the mother “protesting loudly ‘stop that, I don’t like that,’ and ‘you’re hurting me,’ but by the time I could get to the room it was all over.”
According to Peterson, the mother is in a double room in the home’s Alzheimer’s unit, and the events staffers say they witnessed took place sometimes with the curtain around her bed closed and sometimes not.
The police report said Peterson “believes the proper steps were not taken by the nursing home to protect the victim,” who, according to the health agency report, has lived at Hebert’s since 2007 and suffers from “severe cognitive impairment.”
Peterson, who told the newspaper that she is still employed at Hebert’s but will not return to work there, said she was so upset by the incidents and the alleged lack of response that she hired a licensed private detective, Michael Clemente, to work with her.
In a written statement she e-mailed Clemente Jan. 4, she said that nursing assistants “would come to me and be almost in tears because of what they had seen the daughters doing to the mom.”
In her statement to Clemente she wrote that in discussions with other staffers shortly after she began working at Hebert’s “I was told that unusual weird and sexualized events have been going (on) with her daughters for a long time well before I started working here. Later I discovered that some of the aides would not provide care for this patient because they did not want to be enablers to the abuse of both of the daughters.”
According to the health investigators’ report, a supervising night nurse acknowledged being aware of allegations over a period that may have dated back as far as July of 2010, and that concern came from “virtually all” staff members who cared for the resident, including four nursing assistants and three nurses.
A nursing assistant told police of an incident where one of the daughters rubbed Victoria’s Secret lotion over her mother’s body while speaking to her in a tone that “was not one you would expect from someone rubbing lotion on their mother. It sounded like the way someone would say those things to a lover or a partner.”
The night supervisor said she reported that incident, and every allegation brought to her by staff, to the director of nursing services, who, she said, responded that meetings were being held with the daughters and that the situation was being addressed.
She said she was told that the home could not prohibit the sisters “from interfering with or providing care to their mother.”
According to the police account, the two daughters “reportedly have power of attorney over the victim.”
The investigatory report notes that although the night nursing supervisor said she and other staff “were very frustrated by the lack of action by the director of nursing services and administrator, she revealed that she neglected to report any of the allegations to the Department of Health.”
State law requires anyone who witnesses a potential first-degree sexual assault to report it immediately to either state or local police. Failure to report is a misdemeanor that can carry penalties of up to a year’s imprisonment or a $500 fine, or both.
The Smithfield police report, in describing the nature of the Hebert complaint, classified it under “domestic sexual assault – first degree.”
Capt. Michael Rheaume said that because the potential charge was a felony his department turned the allegations over to the state attorney general’s office, which, he said, later told him that it would not proceed with a prosecution.
Rheaume said he could not understand that because he felt the sexual abuse charge seemed appropriate “and that’s why we brought it to their attention.”
Amy Kempe, a spokesperson for Attorney General Peter F. Kilmartin, said several state prosecutors reviewed the case and determined that not enough evidence existed to prove that the alleged actions rose to a criminal level.
She said that if local police discover new evidence and bring it forward, her office would consider it.
She said prosecutors felt that with available information, “the state couldn’t prove sexual assault.”
Rhode Island’s general laws define one form of first-degree sexual abuse as sexual penetration when the victim is not a spouse and is mentally incapacitated, and another when “medical treatment or examination” is undertaken for sexual gratification.
Penetration is defined as intrusion, “however slight,” by any part of a person’s body or by any object into the genital or anal openings of another person’s body …”
The penalty for conviction ranges from 10 years to life in prison.
Capt. Rheaume said he is referring the case to the town solicitor to see if lesser, misdemeanor charges can be filed locally.
Rheaume said of the Hebert’s case, “I’ve never seen anything like it.”
Peterson, the psychiatric nurse, said that after making many fruitless reports in-house and watching the daughters allegedly grow “bolder and more brazen,” she called the office of the Alliance for Better Long-Term Care, an oversight agency that acts as an ombudsman for the state on such issues. The Alliance sent clinical social worker Lori Levine to a meeting at the nursing home for a review of the case on Nov. 30.
Levine told The Valley Breeze & Observer that she anticipated a discussion largely focused on a family that was interfering with a patient’s health care, but instead heard details that she found “very disturbing.”
She said she told the home’s administrators they needed to make an immediate report to the police and that she, herself, contacted the police and the State Department of Health.
The complaints should have been reported “long before” they actually were, she said.
According to Peterson, even after a meeting with superiors the day before Thanksgiving at which she and others again detailed all she had witnessed, “The family was still allowed to be alone in the home with their mother.”
The 59-year-old Peterson, who has also worked at Roger Williams Hospital and for a private physician, said the staff was always told of the daughters, “Leave them alone because they have rights.”
She said the situation put her under heavy stress and made her worry about possible consequences of giving statements, “but I just can’t get it out of my mind, what I saw.”
The Medicare investigation summary also cited a second case where care at Hebert’s was deemed substandard, this one involving a complaint by a resident’s family that she had not had foot care since she was admitted on Feb. 18 of last year and “had a strong odor like she had not been bathed in days.”
It also noted that, concerned over the condition of her feet, the family took her to a podiatrist who said, “The resident appeared not to have her feet cared for in some time,” despite a chronic bunion that required podiatry visits every three or four months.
The podiatrist described her feet as “severely neglected,” with “nails so long that they have begun pinching on the surrounding skin of the neighboring toes.”
In still another incident, the investigation cited a family’s complaint that a female resident fell three times and sustained injuries during her four-month stay at Hebert’s because standard safety items such as gripper socks, her call light, and bed and chair alarms were not in place.
The report noted that the director of nursing services revealed she was aware of the problems with safety devices, “but was unable to produce evidence the facility had implemented … staff compliance with these interventions to prevent accidents.”
The report said the patient’s family moved her to another facility “because of concerns for her safety.”
In listing corrective actions for the health agencies, the nursing home’s administrator, Barroso, wrote that his filing “does not constitute an admission that the deficiencies alleged did in fact exist or the facts cited occurred.”
He said the director of nursing is “no longer employed by this facility,” but told the newspaper he was not at liberty to say whether she quit or was fired. Among other items on the corrections list, including the barring of the two daughters:
* A notation that the administrator “has been counseled … regarding his responsibility to investigate all complaints and allegations to protect the residents during the conduct of investigations and to ensure timely follow-up reporting.”
* Re-educating the staff on the definitions of abuse, neglect and mistreatment, and on time-frames for reporting and implementing new procedures on who reports to whom.
* Counseling specific employees for failure to report in a timely manner.
* Assessing all residents’ needs for podiatry services.
* Imposing suspensions on certain employees.
* Conducting audits to ensure that measures to prevent falls are appropriate and in place according to each patient’s care plan.
The nursing home had been operated since 1947 by the Hebert Family before it was sold in July of 2010 to American Senior Living Communities, which also owns the Mount St. Francis Nursing Home in Woonsocket and others out of state.