Oregon Department of Human Services regulators missed red flags and made missteps that could have prevented the death of an 83-year-old woman with dementia who slipped out of a memory care facility unaccompanied, a state report released this week found. Ki Soon Hyun was found deceased last year on
Christmas Day in a wooded region about half a mile from Mt Hood Senior Living, the troubled memory care facility in Sandy that was supposed to protect her. She spent the night outside, dying alone in the frigid cold. She had moved into Mt Hood Senior Living just two days before her death. The Oregon Long-Term Care Ombudsman, an independent state office tasked with holding DHS accountable for its long-term care regulation, launched an investigation after her death. The ombudsman’s report details numerous problems with the facility, including its lack of a qualified manager or safety plan. It directly implicates state officials with the Oregon Department of Human Services, which regulates memory care and other long-term care facilities, for failing to intervene to protect residents both before and after Hyun’s death. “Every step of the way was a stumble and a failure, initially by a lack of a response, a lack of acknowledging red flags and concerns they knew prior to the resident’s death in December,” Fred Steele, Oregon’s long-term care ombudsman, said in an interview with the Capital Chronicle. Steele said the case is a microcosm of what his office sees on a broader level with the agency’s regulation of long-term care facilities. His report also calls for an independent audit of the agency’s licensing and regulation of long-term care facilities to ensure it protects consumers and follows existing Oregon laws. Calls are growing for the agency to make widespread changes. Sen. Sara Gelser Blouin, D-Corvallis and chair of the
Senate Human Services Committee, said DHS has “systemic failures” and must change its culture. Earlier this week, Gelser Blouin criticized the agency for glossing over child welfare problems in a report it released. “Today’s damning report clearly lays out the latest in a series of heartbreaking failures by ODHS leadership to appropriately protect and support the people in their care, sometimes in apparent disregard of state statute,” Gelser Blouin said in a statement. “These systemic failures impact multiple areas of the department and point to an agency culture that shies away from enforcement and prioritizes provider interests over the wellbeing of the most vulnerable Oregonians.” DHS officials, in its written response to the report, defended their actions and said they acted appropriately in light of the circumstances known at the time. “ODHS makes regulatory decisions based on the evidence it can document and substantiate at the time it conducts its investigations,” Nakeshia Knight-Coyle, director of the agency’s Office of Aging and People with Disabilities, wrote in a letter Thursday to Steele. But public records, emails and correspondence in Steele’s report paint a strikingly detailed picture of missed opportunities and missteps within the agency charged with regulating long-term care facilities that serve about 45,000 Oregonians statewide. Report: Red flags missed In July and August 2023, DHS regulators received complaints about the facility. Yet they did not conduct an inspection until November, finding inadequate staff training, a lack of mandatory background checks on two staffers and frequent understaffing. After finding violations, the agency did not take formal action until Dec. 28 – three days after Hyun’s death, the report said. That action was essentially a reminder for the facility to follow staffing requirements in Oregon law, the report said. Also in November, DHS officials heard about another problem – this time from Mt Hood Senior Living directly. The facility’s administrator had left and the business manager and interim administrator told DHS she didn’t feel qualified to fill in as the interim. “I 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,” the business office manager wrote the state on Nov. 14, 2023. A DHS official responded to the email and said they should hire someone, even temporarily, if they don’t feel qualified, the report said. But there’s no evidence the agency followed up, even though state rules require a licensed full-time administrator, the report said. That business manager was still the interim administrator when Hyun left the facility and died. Even after her death, DHS moved slowly, the report said. The agency failed to follow a state law that requires it to take action immediately in response to a failure of a residential care facility that has caused a serious injury or death of a resident, the report said. It took a month after Hyun’s death for the agency to determine the facility failed in a way that caused serious harm, called a condition of “immediate jeopardy.” Among the agency’s findings: Staff fed people solid food when the physician ordered soft food; residents didn’t receive help with showers or baths, and one resident was left in a recliner for more than eight hours without any offer of food or drinks. Residents also had multiple falls – 11 for one resident – and received wrong medications. And staffers failed to receive the required training. But the report said earlier information the agency had on hand should have triggered that determination, which allows the agency to step in and protect residents. When DHS moved to close the facility on Jan. 26, the agency continued to make errors, the report said. That afternoon, DHS told the ombudsman’s office it planned to move all residents out by midnight that same day, the report said. Yet state law allows the agency to appoint a temporary manager to run a facility so residents aren’t traumatized with a sudden move, the report said. “They further traumatized the residents when they moved them on a dark, rainy Friday night,” Steele said. The report details a late-night move that put 13 of 18 residents in unsafe locations. Eight residents went to facilities that also had licensing problems with insufficient staffing or other issues. Two checked into a hospital, one of them after a fall during the move. Another went to stay with their family – but without their medication. The ombudsman’s staff reached out to the residents, finding that some had their belongings placed in garbage bags, and others were shuffled around to different facilities, losing their medical equipment, paperwork and personal belongings along the way. Agency response In its letter to Steele , the agency insists it acted appropriately. But the agency also said DHS is “not able to address in detail” many points in the report because this is a pending legal matter. “We weighed many regulatory options before determining an order of immediate suspension was essential and that other regulatory tools would be inadequate in protecting residents at immediate risk,” the letter said. The agency said it only uses license suspensions in emergencies to avoid disrupting residents’ lives. Agency officials said they determined they could not keep the facility open with an outside manager and “moved swiftly” to assist residents after the decision. The agency reached out to more than 180 facilities to find places for residents and some of those immediate placements were temporary, the letter said. Rather than defend the rapid move, DHS officials praised their agency’s “fast effort” to coordinate medical transportation, other facilities and agency staff who “worked tirelessly” to help residents. The letter did not address why the agency took the time it did to shutter the facility. DHS spokespeople did not answer a question from the Capital Chronicle about what changes and improvements, if any, the agency will make in response to the ombudsman’s report. GET THE MORNING HEADLINES DELIVERED TO YOUR INBOX SUBSCRIBE