Kept in the Dark: Oregon hides thousands of cases of shoddy senior care
Oregon officials have concealed from the public thousands of confirmed cases of shoddy care and elder abuse, whitewashing safety records at hundreds of homes for seniors across the state.
The Department of Human Services operates a website that is supposed to help consumers identify safe havens for their aging loved ones, including those suffering from Alzheimer’s and other debilitating illnesses.
But an investigation by The Oregonian/OregonLive found that officials have excluded nearly 8,000 substantiated complaints of substandard care from the state’s website.
The newsroom spent months analyzing state records that aren’t available online, compiling for the first time a full accounting of substantiated complaints at Oregon care centers. Reporters wrote computer code to download every online complaint from the website and used the data to identify thousands of missing records.
More than 60 percent of the substantiated complaints against care centers in Oregon since 2005 can’t be found on the state’s website.
The excluded complaints, all validated by the department’s own employees, show cases of elderly residents being punched, pushed, slapped or sexually abused by staff. Other missing complaints describe residents who had valuables stolen or who landed in the emergency room after getting the wrong medication.
The omissions skew the track records of more than nine out of every 10 senior care centers in the state.
“It’s a mess,” said Ashley Carson Cottingham, who inherited the program when she became director of Aging and People with Disabilities program in December 2015.
Most of the omissions are intentional, part of a departmental policy adopted years ago to withhold certain types of information from the public, officials said. Others are due to mistakes in the way state workers classify complaints.
“There is inconsistency all over the place,” Carson Cottingham said.
The agency intends to replace the website and post all new validated complaints online in the future, a spokesman said. But a replacement could be years away because the department has decided to tackle other software projects first.
Sue Crawford learned the hard way that the state’s consumer website can’t be trusted.
With her 93-year-old mother, Marian Ewins, battling dementia, Crawford spent two weeks dutifully touring care centers, interviewing staff and zeroing in on a new place near her home.
She went to her computer and checked the state’s consumer website for Washington Gardens Memory Care in Tigard.
It looked squeaky clean.
No complaints of abuse, neglect or shoddy care had arisen in the entire three-and-a-half years the home had been open.
But the state website did not reveal the 10 times that Washington Gardens had been hit with substantiated findings of abuse, neglect or poor care.
Washington Gardens failed to seek timely medical treatment in 2013 for a resident who died after vomiting repeatedly, turning pale and pleading for help, state investigators found. The state also determined that in 2014 the facility failed to protect one resident from another who had a history of aggression, sending the victim to the hospital after a fight.
And the state found Washington Gardens didn’t do enough to keep a resident with a history of falls from breaking a hip and suffering facial injuries in 2015.
None of this information made it onto Oregon’s consumer website.
Based on what the state website showed and her visit to the center, Crawford expected great care for the woman who decades earlier taught her to sew and sprang for an $80 pink prom dress during lean times, urging her to keep the price a secret from her father.
Crawford was shocked by what she says she witnessed after her mother moved in.
Two days in a row, Crawford said, she arrived for visits to find her mother sitting in her own feces. Ewins was admitted to a hospital with diarrhea and dehydration, hospital records show.
In addition, Crawford said she was present when a staff member discovered that half the drugs in her mother’s locked medication drawer were labeled for another room. According to medical charts that Crawford obtained from Washington Gardens, her mother missed two consecutive days in a week of prescribed blood pressure readings.
Crawford filed a complaint with the state in September 2015. A spokesman for Oregon’s Aging and People with Disabilities program said the complaint was not investigated at the time and that the state has opened a new investigation, two years later.
Frontier Management, the Oregon company that runs Washington Gardens, would not comment on specific cases but said in a statement: “At the time of the alleged incidents in question, we followed applicable policies and procedures, conducted thorough investigations and reported the incidents to the proper authorities.”
Had Crawford known that state investigators linked substandard care to a death at Washington Gardens, she would have looked elsewhere.
“I would not put her in some place that might put her in harm’s way or jeopardy,” Crawford said. She relocated her mother in August 2015, after just three months at the Tigard care center.
The misleading online profile that Crawford found for Washington Gardens is far from unusual. About 600 nursing homes and other senior care centers around Oregon have incomplete records online, The Oregonian/OregonLive’s analysis found.
Officials who run the state’s website say it was never designed to display every complaint. The human services department decided about nine years ago to show only cases that led to a finding of “facility abuse.” The website tells visitors about this omission.
But in interviews and emails, agency managers did not have a clear-cut definition of how they distinguish “facility abuse” from other findings of fault. The Oregonian/OregonLive found hundreds of complaints with the words “abuse,” “neglect” or “exploitation” that the state excluded.
Tom Peine, an agency spokesman, acknowledged that leaders who built the website a decade ago might not have made the best decisions about what to include.
Agency managers also said they didn’t realize the website omitted some complaints that match their own criteria for posting until contacted by The Oregonian/OregonLive.
The state launched the website in 2008 after years of prodding by U.S. Sen. Jeff Merkley, who was a state representative and then speaker of the Oregon House. He was shocked when The Oregonian/OregonLive told him in March that so many substantiated complaints were excluded from the website.
“That’s terrible,” he said.
Putting complaint data online can give consumers valuable information in their quest to find a high-quality center or home, specialists say.
But if the information is not complete, consumers see an inaccurate picture, said Fred Steele, the state’s long-term care ombudsman.
“Touring a facility is only going to show you oftentimes what the physical aesthetics of a building are,” Steele said. “It doesn’t show you what’s actually happening behind the scenes.”
Easy access to information about deficient care helps consumers at a difficult time.
“In today’s day and age, it feels very unacceptable that this information isn’t publicly available yet” online, Steele said.
An industry official, Linda Kirschbaum, said she had no idea that any substantiated abuse complaints were excluded from the website until being contacted by a reporter.
“We support full transparency of completed abuse investigation reports being online,” Kirschbaum, the Oregon Health Care Association‘s senior vice president of quality services, said in a statement.
The state’s Aging and People with Disabilities program has decided to replace one software system and expand another before addressing the website’s shortcomings. Carson Cottingham’s staff said they considered taking the site down but decided to leave it up until whenever it can be replaced. No date has been set. And they have not committed to putting the 8,000 missing complaints online.
The Oregonian/OregonLive is publishing its entire database of substantiated complaints today and intends to update it regularly.
Carson Cottingham’s agency, which previously gave the newsroom the data for free, now says it will charge up to $375 for the time it would take staff to produce updates.
Clean records mask problems
Complaint investigations start when victims, family members, advocates, care center staff or others alert the state to potential cases of substandard care and abuse.
Under state rules, abuse can include an “active or passive” failure to provide basic care needed to keep residents healthy and safe. The written definition encompasses both harm and “risk of serious harm.”
The state’s Aging and People with Disabilities program keeps records of substantiated complaints in an internal database, including narratives of what went wrong. Since 2008, the program has also presented a much less detailed list of complaints on its website.
The Oregonian/OregonLive requested all the state’s substantiated complaints and compared the data with what’s on the web.
The analysis revealed glaring gaps.
Just 9 percent of residential care centers, assisted living facilities and nursing homes had accurate records online.
Of the 642 facilities open as of late last year, 585 had incomplete records at the time of the analysis. Of those, about 350 had more than double the number of complaints shown on the state’s website. Fifty-nine care centers falsely appeared to have perfect records. Just like Washington Gardens, they had zero complaints online. In reality, none of these places were complaint-free.
In all, facilities with incomplete records have the combined capacity to serve more than 35,000 people.
Mistakes that matter
Oregon keeps two sets of books on senior care, The Oregonian/OregonLive investigation found.
The state does indeed track all substantiated complaints of abuse, neglect and poor care in an internal database. Every single record details a facility’s violation of Oregon rules. But the state withholds about 60 percent of the substantiated complaints from its consumer website, the analysis shows.
Oregon still has not clearly told website visitors that thousands of substantiated complaints have been deliberately or accidentally omitted, or that many of those complaints involve neglect and abuse.
Human services officials posted a disclaimer in February that the data “may not always be complete,” months after being contacted by The Oregonian/OregonLive.
The sorts of records hidden from view frequently involve issues that matter to consumers. They range from inadequate care to outright violence and degradation.
In a case at Churchill Residential Care in Eugene, the state’s complaint summary says staff members saw signs that a resident had a stroke one morning in July 2014. They waited four and a half hours to call an ambulance, according to the state record.
The case was not online at the time of The Oregonian/OregonLive’s analysis. The agency said a data entry error caused the omission, which has since been corrected.
A spokesman for the company declined to comment on the specific case, citing resident privacy. In general, however, Churchill Estates believes all substantiated abuse cases should be published online, the spokesman said.
State rules also require centers to anticipate problems such as frequent falls or fights between aggressive dementia patients. Staff members at these centers are supposed to design care plans to minimize risks. When instructions are not followed, residents can get hurt.
An investigator concluded that’s what happened in July 2012 to a resident who broke an arm falling on concrete at Arbor Oaks Terrace Memory Care in Newberg.
Employees didn’t follow the resident’s care plan, which explicitly said the person should always be accompanied to avoid falls, the state found.
Staff members learned about the injury only after another resident found the person on the ground, the state concluded. Investigators also concluded that the resident’s personal physician had asked to see the patient the same day, but the Arbor Oaks staff waited until the following day to take the person to the doctor.
That incident is not online.
Other complaints hidden from public view show residents stripped of their dignity.
A staff member at Quail Park at Crystal Terrace, a Klamath Falls care home, shared a photo on social media in February 2015 showing a resident’s naked buttocks, a state investigator found. The resident was in the bathroom in the picture, the investigator wrote. A caption under the photo said “My job…” followed by three pistol emojis, according to the state’s investigation.
A state investigator later described showing the victim the picture and explaining what happened. The person looked distraught, according to the report.
The home’s parent company in Seattle, Living Care Senior Lifestyle Communities, said in a statement that it fires staff members who don’t follow its policies or Oregon rules.
“In this particular case, after an immediate and thorough investigation, the employee associated with this event was terminated,” the statement said, a fact supported by state records.
The substantiated complaint appears nowhere on the state’s senior care website.
Another investigation, involving Vineyard Heights Assisted Living and Retirement Cottages in McMinnville, found that in December 2015 a caregiver deliberately hit a resident’s head against a bathroom wall. The blow left the victim’s head bloodied, an investigator wrote.
The victim told another staffer, who saw the bloody cut. But that person chose not to report it, the investigation concluded.
That evening, the caregiver who injured the resident took the victim to the shower with help from another staff member, the official report says. The resident started screaming, begging not to be left with the caregiver, according to the report.
The state’s findings indicate the caregiver who hurt the resident was going to be moved to another part of the facility and retrained, but that the caregiver gave notice and left the facility a week after the incident.
The substantiated complaint is not online.
Frontier Management runs both Vineyard Heights and Arbor Oaks. The company responded to questions about the substantiated complaints at those facilities and at Washington Gardens by saying managers followed procedures, conducted thorough investigations and reported incidents to authorities.
Decisions and missteps
One reason the state’s senior care website leaves out so much data is a judgment call: Managers who designed the website almost a decade ago decided to include only certain categories of complaints.
Current and former officials at the human services department could not recall who decided the types of substantiated complaints to keep off the website.
The head of senior services at the time was James Toews, now an acting deputy chief in the federal equivalent for Oregon’s program. He declined to comment about the database.
Peine, the human services spokesman, said the website was designed to include only cases in which the facility is found to be responsible for abuse, not cases in which staff were solely blamed.
Complaints eliminated for this reason include the resident photographed in the bathroom and the resident whose head was hit against a wall. Even though the facilities were found responsible for rule violations that allowed the abuse to occur, the complaints were kept offline because staff members were faulted for the abuse itself.
The state also excludes many complaints that involve no harm, even if agency managers found the problems serious enough to warrant further action.
At Pacific Gardens Alzheimer’s Special Care Center in 2015, caregivers made more than 70 medication mistakes in four months, investigators found, resulting in 17 official findings against the facility. The pattern prompted the state to demand a “plan of action” from Pacific Gardens.
But only one of the state findings is online: a resident who received another person’s medication and became sedated. The other 16 cases ended with no visible harm and are hidden from website visitors.
A Pacific Gardens spokeswoman said the home promptly corrected the medication errors once they were discovered.
Complaints labeled “potential for harm” or “no negative outcome” account for about 2,500 of the substantiated complaints that are missing from the website, or around 30 percent of the records that have been kept offline.
The state fined the facilities in hundreds of those cases.
Carson Cottingham, who oversees the consumer website, said some complaints don’t appear online because state employees have been inconsistent in how they code complaints.
Other staff errors have kept some complaints off the web, even when they met the state’s criteria, agency staff acknowledge. Among them was the death that Sue Crawford should have been able to see when researching Washington Gardens.
Leslie Ross, who manages a website on long-term care in California through the University of California, San Francisco, said consumers would prefer to simply see every substantiated complaint — no matter what happened or who’s at fault.
What can’t be found
It’s hard to predict which cases of substandard care will end up online and which will not.
For example, state records show there were at least 11 thefts from residents at Emeritus at Springfield-The Woodside, an assisted living facility, in a three-month period in 2013. One resident reported missing $300. In each case, the state faulted the facility for failing to provide a safe environment for residents, a violation of Oregon’s long-term care regulations.
None of these substantiated complaints are on the state’s website.
Yet very similar complaints — made in the same year, against a care center with the same owners, and located in the same city — are all online.
Search the state website for “Emeritus at Springfield-The Briarwood,” and you’ll find records corresponding to thefts of two fishing poles, tackle boxes and $370 in cash.
Both facilities have a new owner, Brookdale Senior Living, and have been renamed. A spokeswoman said that the safety and well-being of residents is the company’s top priority. The spokeswoman also said Brookdale complies with the state’s reporting requirements.
Even when all complaints against a care facility make it online, they can’t be found easily if the center changes hands. Previous complaints are listed under the home’s former name, which a consumer may not know to check.
Of the roughly 650 care centers licensed in Oregon, more than a quarter have complaints that can be found only under their previous names.
River Grove Memory Care in Eugene, for example, shows four complaints racked up since the current owners bought it in 2015. However, searching for the home under three of its previous names and owners shows an additional 31 complaints. Seventeen of those happened in the two years before the current owners took over.
It would take a thorough knowledge of the home’s history to find them. River Grove used to be Santa Clara Special Care Community. Before that, Sierra Oaks of Santa Clara. Before that, Santa Clara Residential Inn.
A River Grove representative, Terri Waldroff, said her company has nothing to do with the problems at the center under previous owners. She said the current owners have renovated the campus, added a kitchen and hired new staff.
The facility shouldn’t be associated with the old complaints, she said.
The state’s existing policies support Waldroff’s perspective. But Carson Cottingham said it may be time for the state to revisit its approach.
“I don’t think it gives the consumer a full picture of what’s going on in a facility,”
Giving Oregonians access to each care home’s full compliance history regardless of ownership, said Carson Cottingham, is the “right thing to do.”
Problems known, fixes elusive
The department added caveats to its consumer website after The Oregonian/OregonLive alerted officials to problems.
The site now advises consumers to visit care centers and to call the state ombudsman.
In February, the department added a disclaimer at the bottom of the page.
“Oregon DHS is aware of the technical and other issues regarding some instances where data may not be complete and is working to correct these underlying issues,” the disclaimer says.
The division did not put online the abuse complaints against Washington Gardens for months after being alerted by The Oregonian/OregonLive. In the third week of March, they appeared on the website.
For nearly two years after Crawford did her research, consumers considering Washington Gardens wouldn’t have known about its tainted record. They wouldn’t have known that the center was fined three times after residents fell and hurt themselves, including two who suffered fractured hips. State website visitors wouldn’t have known that a resident had to be hospitalized after a fight. And they wouldn’t have known that a resident died there after vomiting and crying for help that came too late.
Aging and disabilities officials say they don’t intend to mislead the public.
“In no way are any of our decisions ever to limit information from being out there for them,” said Nathan Singer, deputy operations director.
Carson Cottingham wants her staff to eventually replace the website, posting all new substantiated complaints. Agency officials also would like to post all new inspection reports and sanctions.
“My approach is that we need to be fully transparent and to be as helpful as possible,” said Carson Cottingham.
Still, the state has no concrete timeline for making its consumer website complete. Carson Cottingham said any update could be years away.
Her agency plans to replace an internal software system for tracking abuse by the end of the year and to then expand the system that tracks inspections. Only after both projects are complete will the department be in a position to replace the online tool, officials said.
But those projects won’t necessarily put online the nearly 8,000 complaints that are excluded from the state’s website. What’s more, state officials say they plan to scrap the current website, which could move all current complaints offline.
Members of the public can request paper or electronic copies of a facility’s complaint records by contacting the aging services program, agency officials said.
Merkley, the Oregon politician who wanted a website to simplify the process of picking a care facility, was stunned to hear how incomplete the consumer website is.
“You’ve got to have the information to hold an organization accountable,” Merkley said.
Filed under: General Problems