After an elderly resident with dementia living at Mt. Hood Senior Living in Sandy, Oregon, was found dead, state Department of Human Services officials should have immediately acted to ensure the remaining residents were safe. That did not happen.
Ki Soon 鈥淗armony鈥� Hyun, who had dementia, died after she wandered away from the facility in December of last year. The staff at the facility failed to lock and secure doors, a requirement for licensed memory care communities. The state鈥檚 licensing officials waited nearly one month after her death to enter the care facility, according to a damning investigation released by the Oregon long-term care ombudsman this week.
Once ODHS licensing officials entered the facility on Jan. 22, they found a litany of concerning issues ranging from: all of the staff had failed to complete required training; staff were feeding multiple residents solid food when they were prescribed by a physician to have soft diets (an oversight that could lead to aspiration, choking or death); residents were being given the wrong medication; residents weren鈥檛 getting any help bathing or showering; and they left one person in a recliner for more than eight hours without access to food or water.
鈥淚t is clear that Mt. Hood Senior Living failed to protect and care for Ki Soon Hyun and other residents,鈥� the report reads.
In a three-page letter, Fariborz Pakseresht, head of ODHS, and Nakeshia Knight-Coyle, director of the ODHS鈥� Office of Aging and People with Disabilities, said they did not 鈥渁gree with many of the report鈥檚 statements or its representation of the agency鈥檚 options in pursuing regulatory action at Mount Hood Senior Living.鈥�
On Jan. 26, the state moved to rapidly close the facility, a move that likely traumatized the remaining elderly residents forced to flee their homes in the middle of the night, according to the report.
One of the residents who were moved at night, Charles Hess, was found dead in his chair after being moved and after falling multiple times, the report says, adding it was 鈥減otentially related to the transfer trauma.鈥� His family was not notified that he was moving nor told where he was going. The new facility did not have the medical equipment he needed.
The leaders of ODHS said they 鈥渨eighed many regulatory options鈥� before suspending the facility and did so after investigations done by other units, including Adult Protective Services and ODHS鈥� Safety, Oversight and Quality.
According to the ombudsman鈥檚 report, there were numerous 鈥渞ed flags鈥� the state missed preceding Hyun鈥檚 death. The report found 鈥渄ue to regulatory inactions and failures 鈥� (the) resident鈥檚 death and the additional harm and trauma that occurred to residents at this facility in the weeks following could have been prevented.鈥�
Leading up to Hyun鈥檚 death, ODHS licensing staff were informed that the facility was both regularly understaffed and also without an administrator. The interim administrator emailed state licensing officials telling them she didn鈥檛 feel qualified for the role.
鈥淚 do not believe I have the credentials, training, or education to fill in as an interim, as I have only been a bookkeeper/Business Office Manager with a High School Diploma; no college education or formal medical training or work experience,鈥� the interim leader wrote in November 2023.
Still, the state didn鈥檛 step in.
Soon after Hyun鈥檚 death, the owner of Mt. Hood Senior Living offered a 鈥渟afety plan鈥� to ODHS, according to the report.
鈥淭hat safety plan included a plan to install an alarm system on certain exit doors, indicating that they may not have had the alarms in place as required by (state rules),鈥� the report states.
The owner of Mt. Hood Senior Living had no experience in elderly care, according to the report. Prior to applying to the state to run the facility, the owner was a real estate agent.
鈥淭he lack of regulatory requirements for an inexperienced owner opening a facility for services to individuals with extraordinary care needs associated with dementia is particularly concerning,鈥� the report reads. 鈥淓nhanced regulatory requirements and expectations must be developed before allowing inexperienced owners to provide these health and safety services in the future.鈥�
The state ombudsman鈥檚 office is recommending an independent audit into ODHS鈥檚 licensing and regulatory duties.
The ombudsman鈥檚 report notes that Oregonians expect that their loved ones will be treated with 鈥渄ignity and respect鈥� when they are put in a state-licensed facility.
鈥淭rust is currently broken,鈥� the report reads.
Copyright 2024
