Disability Rights Arkansas

Centers for Youth and Families Little Rock

*Photos taken by DRA staff during onsite monitoring visits. Photos reflect the most recent conditions observed by DRA staff but may not reflect the current conditions at the facility. If you are associated with a facility and have updated information or photos you would like to share, please contact DRA at [email protected]

Location: Little Rock, AR

Population Served: Youth ages 5-18

# of residents per unit: Up to 8 Residents per room: 1-3 Capacity: 82 beds (PRTF and residential)

Contact with family (Calls and visit schedule): Facility declined to provide specifics regarding call frequency or schedule

Restraint utilized? Yes Chemical Restraint utilized? Yes Seclusion utilized? No

Treatment Components

Clinical Director - LCSW

Therapists: Facility declined to identify, report number employed, or share credential status of any therapists.

Treatment modalities offered: Facility declined to identify any specific modalities available.

# of individual therapy sessions/week: Facility declined to provide a number or range.

# of group therapy sessions led by a licensed mental health professional/week: Facility declined to provide a number or range.

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PRLU or OLTC

Notice of Incident

Injury in Rage Room

  • Client was sent to ACH ER after striking one of the padded walls in the Rage Room. The medical team wanted her hand to be further evaluated to rule out of fracture.
  • Based on video reviewed and interviews conducted, Client put on gloves that were not purchased by the Program Director (unknown who purchased them and placed them in the EMAC Gym); Gloves were thin with little padding. Client punched padded walls that were not intended to be hit or kicked.

Police Report

Non Police Incident

Caller advised they handled the situation and no longer needed police assistance.

Police Report

False or Unfounded Call

Officers responded in reference to a 911 hang up; Upon arrival staff stated that everything was fine. Nothing appeared suspicious or out of place.

Police Report

Disturbance

Officer spoke with staff who stated a Juvenile who had returned from Pinnacle had been breaking things all morning. Staff stated Juvenile was acting up so he could return to Pinnacle in reference to a female Juvenile he met during his stay.

PRLU or OLTC

Visit Compliance Report

Regs out of compliance –

  • R409.6 – Observed 3 holes in wall in kitchen area that need repair. Due date 6.4.21.

Police Report

Harassing Communications

Staff 1 wanted officers to stand by while she picked up final paycheck. Staff 1 stated she wanted to make a harassment report against Staff 2. Staff 1 stated that Staff 2 threatened her life in a group message. Staff 2 also filed a harassment report against Staff 1.

Police Report

Non Police Incident

Officers made contact with facility manager who advised everyone was okay.

PRLU or OLTC

Notice of Incident

Self-Harm

  • Client got mad, went to his room and engaged in self-harm by tying the strings from his paper mask together and placing it around his neck. Staff went in immediately and took action. Per student’s report, he engaged in this behavior as a power struggle and was not attempting suicide. No follow-up details.

Police Report

Assault Third Degree, Battery Third Degree, Information Report

Staff advised Officers that Juvenile stated she was “leaving today on her own or in a body bag”; Staff secured and placed Juvenile in isolation when she tried to choke herself with a face mask. Juvenile punched and kicked Staff members while they attempted sedation. All parties had no visible injuries.

Police Report

Information Report

Officers responded to facility in reference to a 911 hang up call. Officers made contact with Nurse at location who stated everything was okay and police were not needed.

PRLU or OLTC

Notice of Incident

Maltreatment – Staff Abuse

  • Former client disclosed several allegations from his time at facility involving 5 staff members. Client stated his therapist made him suck her breast and played with his private area and made him go down and lick therapist’s private area, threatening him with a knife; This happened 2 times. Client stated that 2 program managers were in office with guns and had sex in front of client, then 1 manager made client perform oral sex on him and penetrated him from behind. Client also stated manager peed down his throat. Client stated this happened 5 or more times. Client also stated 2 other staff members put a card over the camera and had sex with him, client stated this happened 3 times.
  • Child Abuse Hotline was called and accepted. Suspects removed from the schedule immediately due to pending investigation. No follow-up details.

Police Report

Battery Second Degree

Referral was received by AR State Police. While in the care of the facility, Juvenile sustained severe injuries including broken arm by staff member. Nurse on duty at the facility ordered Staff member to administer the restraint. Investigation is ongoing.

PRLU or OLTC

Complaint Survey with POC, Workload Report

  • Complaint #AR00026502 substantiated, Complaint #AR00026504 substantiated, Complaint #AR00026552 unsubstantiated.
  • Regs out of compliance –
    • N 128 – Facility failed to ensure client did not sustain an injury as a result of a restraint. Client #4 was put in a restraint after acting out and attempting to punch staff; Client was complaining about face and arm pain due to restraint. Client was taken to hospital for evaluation and report was received that client’s right humerus was broken and surgery needed.
    • N 132 – Facility failed to ensure a physical restraint was performed safely and was appropriate for the client’s size.
    • N 136 – Facility failed to ensure a copy of the facility’s restraint policy was received by the guardian at admission.
    • N 144 – Facility failed to ensure a Physician’s Order for a restraint was documented.
    • N 145 – Facility failed to ensure a face-to-face assessment was conducted within onehour of the start of the restraint for 4 clients.
    • N 148 – Facility failed to ensure the specific time limit for the restraint order was on the physician’s order for 4 clients.
    • N 152 – Facility failed to ensure that the date/time of the 1-hour assessment was documented for Client #3.
    • N 155 – Facility failed to maintain documented records for ESI reports for Client #2.
    • N 156 – Facility failed to ensure the physician signed an order for a physical restraint as soon as possible to ensure restraint orders were accurate and appropriate & update treatment plan as needed for 3 clients.
    • N 165 – Facility failed to ensure a nurse was physically present to continually assess the safety of a restraint and monitor client during the use of a restraint for Client #4.
    • N 167 – Facility failed to ensure a physician or other permitted licensed practitioner evaluated the resident’s well-being immediately after the restraint was removed for 5 clients.
    • Plan of Correction – Handle with Care Holds (HWC) are no longer used in Destiny’s House, EMAC, and EMCC. Retraining on Nonviolent Crisis Prevention Intervention (CPI) and Emergency Safety Intervention (ESI). Video review by staff on holds done the previous day. ESI forms were revised, and data will be reviewed monthly regarding CPI holds to monitor trends. Both staff involved in the 5/2/21 incident were terminated. Guardians were sent Restraint Policy. Nurse Management initiated ESI audit daily and developed ESI protocol
  • Survey Team Composition and Workload Report –
    • Surveyor 1 onsite 23.5 hours 8am – 6pm; 10 travel hours, 16 off-site report prep hours (04/30/21 – 05/05/21).
    • Surveyor 2 onsite 32 hours 8am – 6pm; 5 travel hours, 6.5 off-site report prep hours (04/30/21 – 05/11/21).
      • Surveyor 3 onsite 18 hours 8am – 6pm; 8.5 travel hours, 5 off-site report prep hours (05/03/21 – 05/05/21).

Police Report

Non Police Incident

Juvenile was transported to Children’s Hospital by MEMS; No other info.

PRLU or OLTC

Notice of Incident

  • Injury – Self-Harm
    • Client was in possession of a plastic object during outdoors time (piece of siding from the building) and was using it to injure herself by scratching her arm. Red linear marks observed on her arm but no breaks in the skin were observed. Area was cleaned with soap and water. No follow-up details.

PRLU or OLTC

Notice of Incident

  • Injury
    • Client was allegedly attacked by peer during outdoors time. Client had a red mark and bruising to left side of face.
    • Client was examined by nurse, client denied pain.

PRLU or OLTC

Notice of Incident

  • Injury
    • Client reported that peer bit him on the back. Peer’s note does reflect that he bit client. Human bite observed to left upper back with redness and breaks in the skin.
    • Client was sent to ER for evaluation, Tdap received. Dose administered in ER and Rx called by ER to CVS.

PRLU or OLTC

Notice of Incident

  • Maltreatment – Staff Sexual Abuse
    • Former client stated that while he was at facility, his therapist would call him into her office where she would undress and ask him to lick her “front” (how he refers to genital area). Client said he refused, and therapist threatened to kill him, showing him a knife. Client said this happened more than once. Therapist is still working at facility.
    • Child Abuse Hotline was called and accepted. Therapist was removed from schedule immediately due to pending investigation. On 5.13.21 hotline call involved another Client disclosing several allegations from time at facility involving two staff members threatening him with a knife and guns, sexually abusing him on different occasions. Corrective Action Plan stated that staff would have no contact with youth at the facility
      per the open investigation

Police Report

Assault Third Degree

Resident at facility stated that while he was trying to calm Juvenile down when Juvenile spit in his face.

PRLU or OLTC

Notice of Incident

  • Maltreatment – Staff Abuse
    • Client stated that Staff member had “flipped a child over a chair” by grabbing the child by the back of the leg, causing him to flip and hit his head on a chair. Client stated that some staff try to make restraints hurt by pulling the child’s arms up further behind their backs. Client stated that marks and bruises are often left on him following a restraint; Client had light yellow bruises that he said were the result of a restraint. Client also
      stated that staff don’t get in a hurry to break up fights between kids and that a child had urinated on his belongings, and nothing was done about it.
    • Child Abuse Hotline was called and accepted. Both staff members taken off schedule until investigation is complete. Waiting for follow-up response from investigator.

Police Report

Non Police Incident

MEMS transported Juvenile to Rivendale in N Little Rock.

PRLU or OLTC

Visit Compliance Report

• No regs noted out of compliance. Visit for Corrective Action Agreement.

PRLU or OLTC

Notice of Incident

  • Resident Suicide Attempt
    • Client was in cafeteria upset when she grabbed a coffee pot, smashing it. Staff acted quickly to get glass away from client. Client cut left wrist with glass while staff were trying to get it out of her hand.
    • Video reviewed: Sliding door for serving area should have been closed after breakfast. Coffee pot should have been placed furthest away from the opening of the serving area due to it being made of glass. No follow-up details.

PRLU or OLTC

Notice of Incident

  • Injury
    • Client fell in shower, hitting the ground and bruised her side. Client told staff and nurse/APRN that she was having a hard time because she heard a pop. Client went to ER. No follow-up details.