A report from the Office of the Long-Term Care Ombudsman in Oregon has called for an independent audit of the state’s Department of Human Services, arguing that the regulatory body missed multiple red flags that could have prevented the death of a senior living resident at the end of 2023.
The Oregon DHS is responsible for oversight of many facets of healthcare in the state, including nursing homes. If the report’s recommendations are followed, the department would conduct more inspections of new facilities and act more decisively to issue penalties and oversight.
An 83-year-old resident wandered away from Mt. Hood Senior Living in Sandy, OR, on Dec. 24. The ombudsman report issued Thursday argued that the DHS mishandled both the leadup and the reaction to that event.
“The events that occurred at Mt. Hood Senior Living… are unacceptable and must be addressed,” ombudsman Fred Steele wrote. “Trust is currently broken. This report and its recommendations are intended to move our state closer to that goal and improve the lives of residents in long-term care.”
His report claims that the DHS was aware in November of consistently low staffing levels and that the facility had been temporarily operating without an executive director. When an interim ED was appointed, she wrote to DHS on Nov. 14 claiming that she wasn’t qualified for the job.
Mt. Hood, which had opened in February 2023, was shut down by DHS following the incident. An abrupt evacuation took place, causing some of Mt. Hood’s 18 residents to be moved without needed medications or equipment. The report argues that a trustee should have been appointed to facilitate a more orderly transition.
The report also argues that DHS violated state law by failing to place an Immediate Jeopardy citation on Mt. Hood within 30 days of the resident’s death.
DHS leaders disputed many of the report’s claims in a response letter Thursday.
“We respectfully do not agree with many of the report’s statements or its representation of the agency’s options in pursuing regulatory action at Mount Hood Senior Living,” wrote Fariborz Pakseresht, director at DHS, and Nakeshia Knight-Coyle, director of DHS’ Office of Aging and People with Disabilities.
They also noted that any delays involving regulatory actions had been exacerbated by workforce shortages.
