SANDY, Ore. — This week, the Oregon Long-Term Care Ombudsman released the findings of a three-month investigation in Mt. Hood Senior Living in Sandy, after a memory care resident was found dead a half mile from the facility on Christmas Day.
Ki Soon Hyun, 83, moved into the memory care facility just two days prior to her death, due to concerns about her dementia.
"She did elope the next day from what's supposed to be a locked, secure setting that is locked and secured to protect people from their dementia state that can cause them to wander, become lost and confused, and potentially succumb to the elements outdoors and unfortunately, that's what happened to her," said Fred Steele, the Ombudsman.
The Ombudsman's report found Mt. Hood Senior Living failed to care for her, and for the other residents, starting at the top with an owner who had no experience in this line of work and trickling down to unqualified employees.
Steele said the state regulators should have picked up on these red flags prior to Ki Soon Hyun's death and should have responded more quickly afterwards. The Oregon Department of Human Services shut down the facility at the end of January.
"Despite the requirement in state law that they respond immediately — and 'without undue delay' is the phrase — it took them 28 days to respond. Then, when they did take urgent action, it was in a way that is contradictory to the expectations of state law," Steele said.
ODHS closed the facility quickly, on a Friday, and gave the dozen or so living there a day to pack up and move out.
Steele said while regulators have the authority to do it, closing the facility by midnight that day came as a shock to him and his team.
"In my eight-plus years in this role, it has never been done. There have been plenty of concerns and immediate jeopardy concerns at facilities in my time, but those facilities tend to go through a process where DHS mandates that a management company comes in, and begins taking over the operation of the facility," he said, "By trying to do it in an evening, and remove everybody out of that facility immediately ... it caused trauma."
The Department of Human Services responded to the report this week a letter, disagreeing with many of the report's statements. The agency defended its quick shutdown of the facility, saying that was their best option to protect residents from potential serious harm.
As part of their response letter, ODHS says Oregon's long-term care system has increased in size and complexity, leading to difficulties in regulatory response. Leaders also said they've recently added a new director focused solely on regulatory and safety issues at the state's long term care facilities.