Workers at a Southeast Portland nursing home that has now reported 14 coronavirus deaths failed to wash their hands, got only one mask per shift and weren’t trained on how to control the spread of infection, the state said Thursday.
Healthcare at Foster Creek has become the site of the largest known cluster of coronavirus cases and deaths in the state, with 50 confirmed cases among residents and staff.
The Department of Human Services began a three-day inspection of the nursing home Friday – the same day The Oregonian/OregonLive reported that 10 Foster Creek residents had died and about two weeks after the nursing home first reported coronavirus cases on its website. Officials on Thursday announced another four deaths at the nursing home.
The inspection led to likely the strictest Department of Human Services action against the nursing home to date, in an order signed by the agency Wednesday.
Its broad findings were unequivocal.
The nursing home “failed to ensure appropriate measures are in place to prevent the spread of COVID-19,” the department said in a report summarizing the inspection findings. The failure “presents an immediate risk to the health and safety of all residents.”
The problems also appear to have endangered staff.
Morgen Crumpacker, a licensed practical nurse who last week described the dire conditions at the nursing home to The Oregonian/OregonLive, has since tested positive for COVID-19.
Crumpacker said she believes she got sick because she used the same mask for a week and a half. She works in the unit that had more than 20 patients either sick with the disease or showing symptoms.
The limit on masks came from the nursing home’s top managers, who told her they didn’t have more to go around, Crumpacker said.
“They said, ‘Here’s your mask. You’re not going to get another one. Don’t throw it away,’” she said.
Between uses, workers put their masks into paper bags, she said.
Crumpacker also confirmed the state findings that workers went from unit to unit and that caregivers wore the same masks with non-coronavirus residents as they did with those who had tested positive for the disease.
In the time between the home’s first confirmed coronavirus cases noted March 27 on its website and April 6, the last day Crumpacker was at work, she knows of only one shipment of personal protective equipment — when the Red Cross delivered gowns, she said.
“That’s all the help that we got,” Crumpacker said.
Terri Waldroff, one of the co-owners of the company that manages Foster Creek and other Oregon senior care homes, Benicia Senior Living, has not responded to multiple emails requesting comment.
Some of the troubles inspectors found in the most recent inspection echo well-documented problems at Foster Creek from well before the outbreak.
The nursing home appears to have consistently shortchanged residents on attention from caregivers. Foster Creek residents get less than half the time with a registered nurse per day as residents in an average Oregon nursing home — 19 minutes compared to 48, according to federal nursing home data.
Last year, the Department of Human Services dinged Foster Creek three times for repeatedly not having enough workers to give care to residents, state records show. In one of the agency’s reports, Foster Creek fell short of the minimum required staffing ratios once out of every three days during a 65-day stretch.
Residents have left Foster Creek in droves, its census dropping from 96 at the beginning of the outbreak to 61 as of this week.
State officials took pains Thursday to describe past and present work to help the nursing home curb its surge.
Multnomah County asked them for help with the Foster Creek outbreak about two weeks ago, said Steve Allen, the director of the Oregon Health Authority’s mental health division.
The state is “putting in place” extra resources in response, including more coronavirus testing, personal protective equipment and beds for infected residents. Health officials also deployed a medical team to assess residents. Twenty residents went to local hospitals for treatment and further assessments as a result, Allen said.
But with fleshed-out findings of Foster Creek failures now in hand, the state has issued concrete mandates. The nursing home must now work with a state-appointed consultant, teach caregivers how to prevent the spread of infection, stick to concrete minimum staff-per-unit numbers and other requirements.
The state will only lift the requirements once federal or state health officials say no more confirmed or suspected coronavirus cases remain at the nursing home, the DHS document says.
Among the 22 problems state inspectors witnessed or learned from staff at Foster Creek: Staff members failed to wash their hands when going from one resident to another or after removing their gloves or touching their face masks and employees got one face mask per shift.
The workers couldn’t get a replacement mask – including in one case when the strap on a caregiver’s mask broke, and even workers in the “Sandy Unit” wore the same mask an entire shift, the report said. Employees told The Oregonian/OregonLive that all of the residents infected with coronavirus were housed in the Sandy Unit.
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Inspectors also said some workers kept the same mask when caring for a resident not diagnosed with the coronavirus after working with residents who did have the disease.
In a direct violation of federal guidelines and a state executive order, the nursing home did not check that staff reporting to work were fever-free and had no other COVID-19 symptoms, inspectors said.
And workers potentially exposed each other to disease because they took their masks off when near colleagues or residents and did not maintain social distance from each other while on smoke breaks, according to the findings.
The Department of Human Services concluded that Foster Creek had violated five state regulations.
The regulations require nursing home staff to monitor residents’ health conditions and report any changes to physicians, require managers to have enough caregivers on the floor, require the facility to prevent dangerous conditions and require staff to use protective equipment properly.
“We have confidence,” DHS Director Fariborz Pakseresht said, that with the new measures in place and cooperation with other agencies “we will be able to turn this thing around.”
Asked if the Department of Human Services could have prevented residents from dying if the agency had taken aggressive action sooner, the director said he was “hesitant to get into what could have, should have been done.”
“We do not want to see one more fatality,” Pakseresht said. “Though we don’t really control the future.”
— Fedor Zarkhin
desk: 503-294-7674|cell: 971-373-2905|@fedorzarkhin
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