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Report calls for enhanced state oversight of Utah long-term care facilities after resident's death

Posted at 5:47 PM, Jun 27, 2023

OREM, Utah — The Disability Law Center just released a scathing report which says more oversight of long-term care facilities is needed by the State of Utah.

The report focuses on 48-year-old Chien Nguyen, a resident at Evergreen Place in Midvale, who died by suicide last year after being transferred to another facility, Hollow Care Center in Orem.

READ: Orem care center employees charged with abuse after patient suicide

His brother Nick Nguyen said he cared for his brother for 15 years. He says Chien struggled with schizophrenia and suicidal ideations.

“My brother he lived with me,” explained Nick. “There would be many times where he would worry about something, he’s depressed and I just let him take the meds and he [was] OK. I talked softly to him. [Found] something fun and then talked to him, let him lay down and he’d be OK.”

Eventually, Chien moved to Evergreen Place, a group home housing 17 people with severe and persistent mental health disabilities.

The facility was shut down in January 2022 for horrific conditions, including raw sewage and bed bugs.

“The challenge there was when it finally got shut down because the county health department saw these issues, not the state, the county health department had to go in and say, 'This is just not a safe place for people to live,'” said Nate Crippes, a public affairs supervising attorney for the Disability Law Center.

Crippes said they realized there was no place for the residents to go.

“I think what we saw then was one of the challenges on our system is when we closed that down, there just weren't good options for people with serious and persistent mental illness,” said Crippes.

Chien was transferred to Hidden Hollow Care Center in Orem, which Crippes said is strange since it’s a facility for people with intellectual disabilities.

“My understanding is he at some point in that process, they found that he had an intellectual disability,” he said, “Though he had gone through high school and nobody had ever diagnosed this before. So, how he ended up there is kind of curious.”

Crippes said Chien’s medication also wasn’t transferred since the new facility was in a different county.

Chien attempted suicide by running out in front of a staff vehicle on April 10, which Nick said no one told him about, even when he visited his brother later that afternoon.

“He looked so depressed, tired, and he just lied down in the back of my car,” said Nguyen.

The next morning, Chien ran in front of a car again and died that same day.

Nick said it’s still painful for him to think about what could have been done differently that possibly could have saved his brother’s life.

“I’m wondering if the staff [knew] he wanted suicide already, how come they don’t let him take the meds? Keep him calmed down? Make sure he sleeps well, you know?” he said. “Why’d he get through the door in the middle of the night? And a car ran over him? I just worry about it.”

In response, the Utah Department of Health and Human Services released a statement, reading in part: “We hurt, especially for people who thought they were in a safe place. We recognize the devastation felt by the family of Chien Nguyen. Anyone who abuses vulnerable individuals through a position of trust deserves to be held accountable. And we are pleased that the Attorney General’s Office has brought charges against the owners of Evergreen Place, which was operating without a license.”