Mentor Network, a for-profit company that operates three homes for developmentally disabled people in Brookings, has shut one of them here amid complaints that a patient’s pressure wound smelled “of rotting flesh” and was ignored for months in 2017.
The resident, who had lost about a quarter of their body weight, underwent surgery to remove dead and decaying skin. Due to privacy laws, names and genders of patients cannot be disclosed.
The Oregonian broke the news Thursday after it received reports from the state through a public records request.
Mentor Network is the parent company for Mentor Oregon, whose goal is to tailor to the needs of each person while enriching their lives, its website reads. It aims to enable people to live as independently as possible in the communities of their choice.
“Nestled in residential neighborhoods across the country, our community-based residences offer 24/7 staff support, expert clinical services and opportunities for individual growth,” the site reads.
The neglect was discovered by Community Living Case Management (CLCM), a company that contracts with the state to oversee disability service providers. Its office determined that the neglect took place for months in late 2017 and even continued after the investigation began, the Oregonian reported.
State regulators found that managers there failed to train staff, provided minimal care and made inappropriate decisions regarding treatment, the report indicated.
“As soon as CLCM became aware of the situation at the home in Brookings, they took action to appropriately safeguard the residents’ health and safety, including increased monitoring and finding new homes for all the individuals,” DHS communications director Angela Yeager told the Pilot Friday.
Mathew Clark, the Brookings program manager for the Community Living Case Management, declined to comment.
“The investigation and its outcomes were focused on the health care of one individual,” Mentor Oregon Director Yvette Doan told the Pilot. “Mentor Oregon leadership was in the region on a weekly basis (following the investigation). In addition, we have a senior-level employee based in Curry County and whose sole responsibility is to oversee our services in that area. We made a number of personnel changes following these events, including in this position.”
“The person in the substantiated abuse report was moved in November 2017 and the other residents were transitioned to other homes by February 2018,” Yeager said. “The home was empty at that point and remained empty when licensing actions were taken, and up to and until Mentor surrendered the license Dec. 11, 2018.”
An investigation conducted by DHS concluded that the Brookings home didn’t have a scale, staff was improperly trained — if at all — and likely didn’t do enough to treat the person’s pain, the Oregonian reported.
“Following these events, we developed an extensive quality improvement plan that we provided to our state and county partners,” Doan said.
As a result of the investigation, the company trained all direct-care staff on strategies to maintain skin integrity and reduce the risk of pressure injuries and now require notification and response protocols in the event of a pressure injury, she wrote.
“They also trained staff on how to effectively partner with home health resources, report and monitor any change in medical conditions, and their obligations related to timely and complete documentation,” Doan said.
Ultimately, Mentor Oregon decided to voluntarily return its license for this home, she added.
The state was just about to revoke Mentor Oregon’s license for the Brookings facility when the company shut the doors there.
“Overarching safety concerns” also prompted officials to temporarily prohibit the company from accepting new residents at any of its 28 homes across Oregon starting in November 2017; most of those were lifted by last January, the Oregonian reported.
The last of the restrictions were lifted off homes last month.
The state rarely takes such aggressive action, issuing similar restrictions only a handful of times in recent years.
“There are five (such) group homes statewide that we can confirm have closed as a result of specific licensing actions since 2013,” according to an email sent from the Office of Developmental Disabilities Services . “Licensing actions can result from complaints, substantiated abuse findings, monitoring done by case management entities or other sources.”
She added that the company has taken extensive steps to train staff and worked with the state to make correct the problems.
“While the company is proud of its work in Oregon,” she said, “if we are going to accept any small measure of credit for a job well done for those we support, we must also acknowledge when our services may fall short.”
The five managers involved were all fired and will unlikely be able to pursue such work in the future, as they would be unlikely to pass a background check in Oregon, officials said.
The Mentor Network, the parent company of Mentor Oregon, is a publicly-traded company that serves about 13,000 people in 36 states. It also provides for-profit child foster care, a program that faced congressional scrutiny following reports of numerous child deaths.
Oregon has 861 licenses for group homes for those with developmental or intellectual disabilities. Regulators plan to continue monitoring the homes to ensure adequate care is provided to residents.
State regulators ask people to report suspected abuse of a child or adult by calling 855-503-7233.
Reach Jane Stebbins at firstname.lastname@example.org .