Little Creek Behavioral Health

It was reported that on 03/10/24, resident was seen by DHS staff, and he was observed to have a bruised upper lip and right knee. The bruise on the knee was yellow and brown, indicating that it had been there a couple of days. He said that both of the injuries had been caused when he was placed in physical restraint by staff members. He was also noted to have slurred speech and he was disoriented, as to what time it was, and where he was. He said he had been placed on a new medication, by a doctor at the facility. Facility is required to make a request before placing him on medication and caseworker is to be notified when resident is placed in physical restraints. Neither of these was completed. Resident indicated that he had been placed in multiple physical restraints; he was so out of it that he couldn’t indicate when he had been placed in any of the restraints. A report was made to AR Child Abuse Hotline and accepted.

Licensing Specialist: Kendra Rice.

Per staff, the resident was involved in a physical altercation with peers on 3/7/24 and 3/8/24 prior to being restrained. Per nursing note after each restraint, no bruises were noted.

Licensing reviewed consent form that was signed by resident’s caseworker giving consent for Zyprexa. Per complaint, the caseworker stated she did not consent to the medication. Nurse Nedra informed Licensing that resident is also given a medication on the approved list for prevention of EPS.

The CACD case was found unsubstantiated.

Licensing received a complaint from resident’s caseworker, stating the resident alleged a staff member threw resident on the ground when she attempted to run off the unit on 3/3/24. Resident also reported that the other children at the facility have placed each other in the clothes dryers and that staff do not monitor the laundry room. She said the children put each other in the dryers when they get mad at each other. She said that she feels uncomfortable because only male staff members put her in restraints. A report was made to the AR Child Abuse Hotline and accepted.

Licensing Specialist: Kendra Rice.

Licensing visited the facility and reviewed the restraint packet and other documentation. Per documentation, staff member placed resident in a one person hold and escorted resident back to the unit. The timeframe was from 15:23 to 15:26. Program Coordinator requested a witness statement from staff member mentioned in the complaint.

Facility submitted ICA for staff member and it was approved by licensing. On 3/27/24, facility provided training documentation for staff member involved in incident.

The CACD case was found unsubstantiated.

Resident reported she was choked by staff during a physical hold on 2/27/24, resulting in her breathing being restricted, her face turning red, and him leaving marks on her neck. Accused staff has been placed on admin leave. Report was made to AR Child Abuse Hotline and accepted.

Licensing Specialist: Kendra Rice.

Facility reported that resident reported the incident while on a phone call. Facility also reported there is no camera footage of the incident due to camera footage is not available after 72 hours. Facility submitted an ICA for staff member involved.

Facility provided retraining documentation for staff member named in complaint on 3/13/24. Program Coordinator reviewed restraint packet and received documentation on 3/14/24.

4/23/24 – CACD case found unsubstantiated. This complaint has been unfounded by Licensing.

Resident walked off the unit to say “hey” to her teacher. Staff attempted to guide resident back to the unit, and resident said, “Not to touch me. ” Staff continued to guide her, and resident fell to the floor and sat there. Then staff attempted to help resident off the ground by picking her up, and when lifted off the ground, her shirt raised, resident stated her “boobs are out”. Staff continued to escort her. Resident could pull her shirt down and cover herself when on the unit. She then attempted to leave the unit again and was escorted back; while being escorted, resident physically attacked the staff by kicking staff. Staff then left the unit to assist in other areas of the building. No injuries noted. Called into the hotline, not accepted. Staff will be retrained in escort through handle with care instructor.

Licensing Specialist: Clayton DeBoer.

Facility visited and video reviewed of incident. Staff observed standing/walking one on one with client towards Starfish living unit, staff’s arms under client arms. Client drops to the floor. Staff then, still having his arms under client’s arms, drags client on the floor into her living unit. Other staff viewed standing within arm’s length of this incident and did not assist. Resident was on Unit Restriction and had left her unit resulting in staff initiating the escort. Escort was viewed as inappropriate and possibly physically harmful, as resident was dragged on the floor.

Facility cited 109.1g: Engaging in behavior that could be viewed as sexual, dangerous, exploitative, or physically harmful to children. 905.4g: The following disciplinary actions shall not be used: Physical injury or threat of bodily harm.

12/21/23 – Licensing Specialist Clayton DeBoer-reported this incident to the child abuse hotline and it was not accepted for investigation. Email was sent to Jlynn Perkins of Little Creek indicating that the staff seen in the video that witnessed the incident will need to be retrained on proper escorts. Perkins stated staff will receive retraining from on-site trainers 12/21/23. Training sign-in sheets for staff provided to licensing by 12/27/23. “This was not a maltreatment investigation nor a licensing complaint.”

On 12.12.23, resident was found to have contraband. The contraband was a vape pen that she claimed to have been bought by a staff member who she claimed to be dating as well. Staff has denied all allegations of providing the resident with contraband and being in a relationship with the resident. The staff has been placed on administrative leave pending external investigation. The incident was called into the child abuse hotline twice (by the risk manager and by therapist): both accepted and assigned to a DCFS worker.

Licensing Specialist: Clayton DeBoer

12/14/23 – Facility visited regarding complaint. No definitive evidence this visit to support contraband on campus nor support inappropriate relationship between A/V and A/O.

CACD case found unsubstantiated. As a precautionary measure, staff will be retrained on staff/client boundaries. The complaint has been Unfounded by Licensing.

Licensing received a complaint stating a client had a medication error on 10/15/23 when she took another resident’s medication. The guardian requested that the resident be seen by a physician outside of the facility for follow up and the facility reportedly denied this request. The report stated the resident had felt “high” after taking the medications and the facility reported they monitored her vitals which remained within normal limits.

Licensing Specialist: Clayton DeBoer.

The facility DON provided additional information to licensing that an LPN administered the incorrect medication and approximately 20 minutes later it was discovered the client had taken the wrong medication. Orders were given for monitoring. DON provided nursing notes, correspondence between facility and guardian, and MAR for client. Licensing complaint unfounded.

T/A provided 907.2: The nurse did not provide the level of supervision necessary to ensure the safety of a resident during a medication pass when she failed to follow the agency’s two patient identifier requirement. This led to a resident receiving the wrong medications. The nurse was retrained on the medication pass procedures and received disciplinary coaching.

Client asked to contact the Child Abuse Hotline with neglect complaints. Client stated staff are breaking confidentiality, the nursing department sits on their phones and does not help residents when in need, and a therapist told one of the residents to “kill herself.” Child Abuse Hotline was called, not accepted.

Licensing Specialist: Clayton DeBoer.

Facility visited and multiple clients interviewed. Statements from clients:

– Client stated “all they do is smoke and get high”.

– Client stated she had been sick due to a new medicine, and nurses will not help her. She tried to refuse the new medication but was afraid it would make the nurses mad. Multiple clients complained about the nursing services.

– Client stated she had an accident one morning in which she urinated on herself, and a staff member started the nickname “Pissy [Client]”.

– Multiple clients stated a therapist told a client to kill herself. Four of the six clients interviewed referenced this therapist unfavorably.

– Client stated staff are disrespectful and a staff member called her a “retard” a few months prior. Client reported she did not remember staff’s name and had not seen this staff member in 2 weeks.

An in-service was scheduled for the therapist referenced in the complaint. No definitive evidence that staff member referenced is responsible for the deragatory nickname a client mentioned. As a precautionary measure, all staff will complete in-service training on 10/26/23 (“Do’s and Dont’s” section of BHA).

Licensing complaint unfounded.

While on unit, staff and client exchanged words (unclear from audio). Client kicked a table towards the staff member, who then removed the table from the unit. Client then stood out of his seat and aggressively walked toward staff, and staff failed to use a proper PRT single-man restraint to transition client to the floor. No injuries noted. Staff placed on administrative leave. The Child Abuse Hotline was called (screened out).

Licensing Specialist: Clayton DeBoer.

Facility visited and video reviewed. Video shows that staff did not use unnecessary force when taking client to the ground. However, although client approached staff rapidly, client was not causing injury to himself, peers, staff or property when this hold was initiated. Facility cited 905.10.

Facility advised that staff will not be returning to the facility and is no longer an employee.