EDMOND —

An Edmond nursing facility lacked an effective system for investigating and reporting abuse and failed to consult with a resident’s physician when there was an injury, according to a report.

The Edmond Sun obtained a copy of the 131-page investigative report conducted by the State Health Department.

Click here to download a copy of the 131-page report.

The agency’s investigation was triggered by a Sept. 16, 2008, incident at Grace Living Center, 2520 S. Rankin St. On that day, a resident, Lester Pendergraft, age 93 at the time, allegedly sexually assaulted a 67-year-old resident.

The Health Department’s survey was completed on Sept. 26 and the agency received Grace Living Center’s plan of correction on Oct. 21, said Henry Hartsell Jr., the agency’s deputy commissioner of Protective Health Services.

Hartsell said a $10,000 penalty resulting from the inspection has been proposed by the Centers for Medicare and Medicaid Services. The facility requested a hearing on the penalty, and it is pending before the CMS Regional Office in Dallas, he said.

Last week, the Oklahoma County District Attorney’s Office charged Pendergraft with one count of rape by instrumentation.

Pendergraft died at age 94 at 1:20 p.m. Monday, said Scott Rowland, first assistant district attorney with the Oklahoma County District Attorney’s Office. The DA’s Office verified the death, and the next step will be dismissing the charges, likely to occur on Wednesday, Rowland said.

The office wanted to express its sympathies toward the victim’s family and Pendergraft’s grieving family, Rowland said.

In a statement issued last Thursday, Grace Living Center said it took immediate steps to provide for the safety and care of residents, reported the incident to police and removed Pendergraft from the facility.

“We have cooperated fully with authorities throughout the investigation,” the company stated.

Report findings

Documentation showed the victim’s daughter was notified at 8:45 a.m., 1 hour and 35 minutes after the incident occurred at 7:10 a.m. Edmond Police arrived shortly after they were notified, at about 9 a.m. The victim’s doctor was called between 8:15-8:25 a.m., shortly after he arrived at his office.

On Sept. 25, the detective assigned to the case said, “The facility did a poor job of protecting the evidence.” He said facility staff threw away evidence and washed the victim’s bed linens and clothing and Pendergraft’s clothing.

According to the report, in an abuse or neglect incident, the facility’s staff are to notify the director of nurses and the doctor, get the resident out of harm’s way and assess the resident “the minute you find out there is an allegation.

“The resident was not assessed timely after the incident,” the report stated.

The detective said someone in charge said to another officer that he felt “The situation was being blown out of proportion.”

Citizen advocate Wes Bledsoe, founder of A Perfect Cause, an advocacy organization for disability and elder rights, said when he read the report he was “deeply disturbed” because two individuals who came to the facility for care were affected.

Bledsoe said what was most shocking was that the incident happened in the first place, that evidence was destroyed with either intent or by incompetence and that a staff member voiced concern about police blowing the situation out of proportion.

Furthermore, there were warning signs before the incident that Pendergraft posed a threat to residents, Bledsoe said. Pendergraft was entering rooms of residents who could not call out for help, Bledsoe said.

According to the report, a certified nurse aide reported before the Sept. 16 incident that she observed Pendergraft touch the leg of another resident who was dependent on staff for assistance. The same day, Pendergraft was seen pulling up the shirt of still another resident who was dependent on staff for assistance.

“I hold the facility accountable for this, if not more so than the assailant in this case,” Bledsoe said.

Bledsoe praised the DA’s Office for breaking new ground by charging Pendergraft and making him a known threat to others, and he praised the Edmond Police Department for their investigative work. marks@edmondsun.com | 341-2121, ext. 108