Praxis of Louisville by Landmark Recovery Cited for Three Deficiencies

Landmark Recovery was cited for three deficiencies regarding the murder at Praxis of Louisville by Landmark Recovery.

Here are the findings:
1. Failure to Conduct Required Patient Observations: 

• Landmark Recovery’s Patient Observations Corporate Policy requires staff to conduct “Q Checks” at least every 30 minutes for the first four days of each treatment episode.
• A review of security footage confirmed that the Licensed Practical Nurse (LPN) and Patient Engagement Specialist (PES) on duty failed to conduct the required observations for Ms. Knight prior to and after the assault. 
• The PES acknowledged entering Q30 observation entries into the medical record system without conducting the required visual checks of the patient, as mandated by the facility’s internal policy. This practice constitutes a violation of established observation and documentation protocols. 
• Ms. Conrad, Ms. Hibbs, and Ms. Nelson were aware of this policy violation at the time of the site visit. 
• Ms. Conrad stated that Mr. Ochs, the PES, was terminated as a result. However, Mr. Ochs contested this statement and said that he voluntarily resigned. 

2. Failure to Enforce Restricted Access to Patient Living Quarters: 

• Facility policy states that patients may not enter other patients’ living quarters. 
• Security footage showed multiple instances of patients entering other rooms, including Ms. Hensley entering Ms. Knight’s room multiple times. 

3. Failure to Provide Appropriate Medical Response for Withdrawal Management: 

No clear documentation was found indicating that the prescriber had been notified of Ms. Hensley’s inability to receive her prescribed medication.

According to 908 KAR 1:372, Section 2, protocols must be developed and supported by a physician knowledgeable in addiction medicine to ensure appropriate care when a patient’s condition deteriorates. 

A review of Ms. Hensley’s medical records confirmed she was prescribed Diazepam upon re-admission on 01/22/25, as she had previously been prescribed Diazepam at The Brook. 

A treatment team note dated 01/29/25 stated, “Angela is currently prescribed a Diazepam taper but has not been able to receive this medication due to having a pharmacy lock from insurance.”

Medical records noted Ms. Hensley experienced withdrawal symptoms, including restlessness, runny nose, and anxiety, and continued to experience auditory hallucinations. 

Not only does it sound like this death was preventable, but these are the same issues I have heard about at other facilities. It sounds like Landmark has a lawsuit on its hands. They were dinged for not performing patient checks and falsely stating that checks were completed. Ms. Henlsey wasn’t given her prescribed medication. Sounds like an insanity defense.

Here is how Landmark Recovery plans to correct the findings:

• Performing daily checks of surveillance cameras and requiring an administrator at each facility to visually check camera records to confirm that patient observations were completed.
• The immediate termination of staff members if they are found to be falsifying patient observations.
• Requiring patients to sign an additional consent form upon arrival to indicate they agree not to enter other patients’ rooms and termination from the treatment program for a second violation of the policy.
• Assigning staff to monitor residential hallways for loitering patients.
• Assigning an administrator to review camera footage weekly for patients who enter rooms inappropriately to ensure proper compliance and monitoring.
• Requiring the director of nursing to escalate details about the inability to receive patient medications, sending that information to the compliance department and attending provider (Landmark claimed Hensley did receive the medication she needed while in treatment.)

I am calling bullshit here. Time and time again, Landmark has refused to make the necessary changes. This has been a recurring issue since day one. I don’t see it getting any better. How many more people need to die inside a Landmark facility?

When WTHR reporter asked Matt Boyle for a statement after the findings, Matt lashed out. Matt texted back with, “Do you ever fucking stop? Seriously I hope you burn in hell.”  Matt emailed the following statement: “As it relates to the confidential findings you somehow claim to have obtained regarding the sentinel event at our facility in Kentucky, I have attached evidence that our plan of correction was accepted by the state and our license remains in good standing. It is standard practice for regulatory bodies to review licensed facilities. Virtually all reviews reveal opportunities for performance improvement. Responding to opportunities with a plan of correction is a routine and important part of the quality improvement process in behavioral healthcare. I will further remind you that this particular facility operated for over eight years and served over 10,000 patients without a single sentinel event. I believe the state’s decision not to take action against our license reflects this reality.” Wow Matty, way to play the dicktim.

You can read the news story here.