Licensing Specialist:Clayton DeBoer
Children’s Records reviewed. All items are present in a hardcopy file except for daily/nightly observations, which were present in a separate file.
PRLU or OLTC
Visit Compliance Report
PRLU or OLTC
Complaint Survey
Complaint #AR00033801 was in compliance.
PRLU or OLTC
Notice of Incident, Suicide Attempt
Resident gave staff members a letter that included suicidal ideations. A short time later, the resident was found in the bathroom with a pair of pajama pants wrapped around her neck. Staff members restrained the resident and retrieved the pants.
The resident was placed on Suicide Precautions and 1:1 ratio unil further notice.
PRLU or OLTC
Elopement, Notice of Incident
Resident eloped during a trip to the Ankle and Foot Clinic in Little Rock.
Resident returned to the facility on 7/26/2024.
Police Report
Police Report
Officers responded to the facility in reference to a resident taking medications she had been pocketing. Officers assisted as Pro Med Ambulance Service evaluated and transported the resident to the hospital.
PRLU or OLTC
Notice of Incident, Suicide Attempt, Visit Compliance Report
Staff attempted to wake the resident up, but she was groggy and couldn’t stay awake for very long. It was determined that the resident had been “cheeking” medication and took several medications at one time. The resident was transported to the Emergency Room via Emergency Medical Services (EMS) for treatment.
Licensing Specialist: Clayton DeBoer
Facility was visited in response to incident. Camera footage was reviewed. Some, but not all clients were viewed opening their mouths after medication was administered.
Inservice training on sweeping the mouth after medications are taken was provided to Licensing by the Director of Nursing.
Facility was cited. 907.2.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist (LS): Clayton DeBoer
Personnel Records reviewed. All items present in files. No citations.
PRLU or OLTC
Notice of Incident, Suicide Attempt
Client was told to wash her hands and line up for lunch. Staff felt she was in the bathroom too long and went to the bathroom to check on her.
Staff found her on the floor with a sheet wrapped around her neck. The client did not require any medical attention and was placed on 2:1 (two clients, one staff).
PRLU or OLTC
Notice of Incident, Self-Harm
Client was placed on 2:1 with staff due to threats to harm herself earlier in the day.
Around 1910 hours, staff found her in her room, making movements under her covers. When staff members asked her what she was doing, the client stated, “nothing.” Two staff members went into the room and pulled the covers back. The client had taken off her pants, attempting to pull them up to her neck. She was placed in a personal restraint so the pants could be removed.
Client continued on 2:1 (two clients to one staff).
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer
Licensing Specialist conducted an after-hours visit. Census: 18. Staff/client ratio: 4:18.
Hall 1 staff/client ratio: 1:5
Hall 2 staff/client ratio: 1:7
Hall 3 staff/client ratio: 1:6
All staff alert, awake, and attentive. Night visual check logs were observed. MARS checked. All initialed and up to date.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
Two allegations of abuse were made regarding client and two staff members. Client alleged a staff member poked her ring into the Client’s arm during a personal restraint, approximately a year ago. Client alleged a second staff member twisted her arm during a restraint on 4/24/24.
Licensing Specialist: Clayton DeBoer
Licensing Specialist visited facility. There is no video of alleged incidents as video recorder does not go back to 4/24/24. No nursing note or restraint incident report could be found for that date. Client interviewed. Client stated that staff member twisted her arm during a personal retraint and another staff member called her “dot to dot”. All staff will be given in-training on professionalism with clients.
Complaint has been determined to be UNFOUNDED by Licensing.
PRLU or OLTC
Notice of Incident, Suicide Attempt
Client took the metal from the paper towel dispenser, and cut herself up pretty good. All superficial, but numerous cuts. Police and Ambulance are here, and she is being sent to the ER, then acute.
Email sent to facility to notify licensing if/when client returns to Delta from acute and what safety plan will be.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact, Visit Compliance Report
On 3/13/24, client reported to staff, “roommate was right next to her bed last night during the night when she turned around. Client stated roommate then kissed her on the cheek, got in her bed with her then asked if she wanted to have sex”. Client stated “NO” and put her covers over her head. Client stated peer tried to kiss her on the mouth, pulled her shirt up and felt her breast. Client stated “I just I cant go through this tonight again.” Clients were separated that night (03.13). A report was made to the AR Child Abuse Hotline and accepted.
Licensing Specialist: Clayton DeBoer.
Per facility report, a power surge 3/7/24 damaged cameras for Hall 1, where the alleged incident occurred. Facility is waiting for the cameras to be repaired or replaced. Night checks reviewed for 3/11/24-3/12/24 between 8:00pm – 12:00am. All checks conducted according to print out. Client interviewed. She reported that alleged incident occurred in between staff checking on her room.
Facility cited 110.12: Staff reported this incident to licensing late. Email from facility received stating there was no valid reason for late reporting. She got busy and forgot.
CACD investigation was unsubstantiated. Licensing investigated this complaint and determined it to be unfounded.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Buildings & Grounds conducted from 9:30am – 10:30am. Census: 19. Hall 6 observed. MARs checked. All initialed and up to date. Background checks review completed for all employees.
Facility cited 911.6: Room 67, had a loose toilet seat, Room 68 bathroom had a torn hole in wallpaper, and Room 70 had two droopy ceiling tiles. Maintenance notified during today’s visit.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Annual Review/Policies/PRTF checklist completed. All items accounted for. Background checks reviewed for 20 personnel files. All background checks accounted for.
Police Report
Battery
Police were dispatched to Delta Family Center where a juvenile subject was detained on the ground. Upon arriving police placed the subject into custody and de-escalated the situation. Police spoke with staff who stated she would look for a detention center to place the juvenile.
While standing at the entrance, staff advised that the juvenile grabbed Mrs. Kesee’s shirt and was pushing her around. Staff advised that before he could punch Mrs. Kesee, they took him to the ground and restrained him. The juvenile’s case worker who was on the scene advised that they would take the subject back to where he was previously placed. Staff were speaking amongst themselves stating several things that were visibly upsetting the child and had the potential to re-escalate the situation.
Ms. Tanksley advised that the Juvenile could be taken to the police department. He was transported to the police department until they could find placement. Mrs. Tanksley contacted police and advised they could not place the juvenile and that Delta Family Center had filled out an affidavit over the incident. The juvenile was remanded into the custody of his case worker who transported him back to Sebastian County, in the custody of DHS.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer
Buildings & Grounds conducted from 10:00 AM – 11:30 AM, Census: 20. Classroom 1 staff/client ratio: 2:7, Classroom 2 staff/client ratio: 6:12. Sleeping areas, showers, bathrooms, cafeteria, and grounds observed. MAR checked. All initialed and up to date.
Facility cited 911.6: Torn/missing tile behind toilet in room 23. Maintenance notified.
Facility cited 912.4: Bathroom in room 25 had strong urine odor and stain behind toilet. Housekeeping notified.
Video camera footage reviewed for the early morning hours of 12/4/23 and 12/5/23. All night visual checks conducted within 30 minutes.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
Upon reviewing a physical restraint completed on client on 11/13/2023, it was observed Behavior Coach did not utilize proper restraint procedures. He intervened solo, grabbed his neck and slammed him on the floor. The critical incident indicated the resident threw a desk, but this did not occur, as observed in review of video today. He laid the desk over on the floor and was no danger to self or others.
Licensing Specialist: Clayton DeBoer.
Facility visited 11/21/23 in response to provider reported incident that staff had used or initiated an inappropriate hold with client. Video reviewed. Client is seen sitting in a desk, periodically getting up with an object. After what appears to be a brief exchange between staff and client, staff walks towards client, grabs his arm, and used his left arm, palm flat on client’s back and guides client to the ground. Other staff are present for entire incident and are seen immediately assisting staff in hold by securing client’s extremities.
Facility cited 905.10 for staff initiating physical restraint whilst client was not, at that point, a threat to himself, other people or property. Staff will be retrained on initiation/intervention of holds and level of holds. Staff is currently on suspension and will complete training before returning to work.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Facility visited from 9:30AM-12:00PM. Annual Review/Policy PRTF checklist completed. All items on Annual Review/Policy PRTF checklist accounted for.
Camera footage reviewed for the early morning hours of 11/3/23 and 11/4/23.
Staff observed awake and moving throughout hallway but did not walk the full length of the hallway to conduct checks for a 37-minute interval. Facility cited 907.6: Supervision during sleeping hours shall include a visual check on each child at least every thirty (30) minutes.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Building & Grounds conducted from 10:30am – 12:00pm. Classrooms, sleeping areas, bathrooms, and grounds viewed. MARs checked for 5 residents.
Facility cited 9.911.6: Room in Hall 6 had water spots on ceiling tiles. Hall 2 had broken/sagging ceiling tile.
Video was reviewed for the early morning hours of 10/15/23 and 10/16/23; All night visual checks viewed were conducted within 30 minutes.
PRLU or OLTC
Complaint Survey with POC, Revisit Survey
Complaint #AR00030833 was not in compliance, all or in part, with deficiencies cited at N128 and N132.
N128: Facility failed to ensure a physical restraint was implemented without injury for Client #1.
N132: Facility failed to ensure a physical hold was performed in a safe manner for Client #2.
Plan of Correction: All staff were retrained on proper CPI techniques and CPI Instructor/Dept. of Education Director will review camera footage for a minimum of 3 restraint holds per week and document findings until licensing unit determines deficiency is corrected and goal of 100% compliance is met for 4 consecutive months.
A revisit was conducted on 12/13/23, for all deficiencies cited on 10/11/23. All deficiencies have been corrected, and no new noncompliance was found.
Medicaid Inspection of Care
Corrective Action Plan, Inspection of Care Report
Deficiencies were noted during the Inpatient Psychiatric Inspection of Care (IOC) conducted on 10/02/23.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Chelsea Vardell.
Licensing and staff met to discuss the progress of the current Corrective Action Agreement made on 3/22/23. Due to recent citations involving the use of inappropriate behavior management by staff, the current CAA will be extended an additional 3 months. Two new requirements were made on the CAA. Staff have been retrained on their restraint hold procedures prior to today’s meeting.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
Client accused staff of hitting him during a physical hold. Nurse noted redness and swelling on client’s face. The Child Abuse Hotline was then called and staff went home. Staff will not be coming back to work until a safety plan for him and client is in place and has been approved.
Licensing Specialist: Clayton DeBoer.
Licensing visited facility and interviewed client and roommate. Client stated he received injuries to his face “because we was fighting”. When asked, client stated he was fighting staff and could not remember what exact movement by staff resulted in him sustaining injuries to his face. Client’s roommate stated that client did not have any injuries to his face prior to this altercation with staff. His roommate stated that staff struck client “3 times in the face…with a closed fist… was on the ground on his back and [staff] was on top of him” and that client had blood coming out of his ear.
The following regulations were cited:
– 905.4.g: Staff inflicted physical injury to client during a restraint.
– 907.2: Two staff member failed to assist a third staff member calling a code yellow, asking for assistance, which resulted in the injury of a client.
Licensing and CACD complaint substantiated. Licensing was informed that staff was terminated as of 11/10/23.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
On 9/15/23, client was placed in a restraint by staff. Client said the staff member came into the classroom, told her he was tired of her and was going to punch her in the face. Client said staff grabbed her by the arm to take her to a timeout, pulled her out of her chair, slammed her into two desks and then onto the ground. Client said she later noticed a bruise on her thigh and attempted to show the nurse, who told her she could not do anything about it.
Licensing Specialist: Clayton DeBoer.
Licensing visited the facility and viewed video of the incident. Staff is seen approaching the desk client is sitting in, takes client out of her seat, over a desk that falls over and to the ground for a hold. Additional staff are seen assisting with the hold.
A staff witness was interviewed who stated stated that upon arriving to the classroom, the staff member made a threatening statement to client referencing being quiet. Staff then asked client to go to timeout and client refused, and at this time the physical confrontation ensued.
CACD and Licensing investigations were substantiated. Staff member was terminated.
Facility cited 9.905.4.g: Client sustained injury from physical confrontation with staff.
Facility cited 9.905.10: Staff initiated a restraint on client without client being a threat to herself, others or property.