Disability Rights Arkansas

Little Creek Behavioral Health

*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: Conway, AR                       Population Served: Non-Arkansas residents ages 6-21. Deaf and hard of hearing unit.

# of residents per unit: up to 8 Residents per room: 1-2 Capacity: 64

Contact with family (Calls and visit schedule): Weekly to Bi-weekly calls. Visits with families are scheduled (no additional details were provided).

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

Treatment Components:

Clinical Director: LPC-S                    Therapists:4 full-time therapists (2 LMSW, 1 LCSW, 1 LAC)

Treatment modalities offered: “Trauma-informed Care, Cognitive Behavior Therapy (CBT), Eye movement desensitization and reprocessing (EMDR) and Reality Therapy, Person-Centered and Deaf Mental Health.”*

# of individual therapy sessions/week: 1-2

# of group therapy sessions led by a licensed mental health professional/week: 2-3

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PRLU or OLTC

Notice of Incident

  • Assault
    • Client was upset and began to attack staff. Peer became upset client was attacking staff, so they charged at client and knocked them into a wall.
    • Client noted to have slight bleeding around gum line of left central incisor and left lateral incisor with both teeth noted to be loose. Client has appt on 8/31/21 for dental evaluation. The dentist notes that no further treatment is needed.

PRLU or OLTC

Notice of Incident

  • ER Visit – Possible Appendicitis
    • Client was complaining of severe stomach pain, so she was sent to the ER due to possible appendicitis. No follow-up details.

PRLU or OLTC

Technical Assistance, Visit Compliance Report

Specialist discussed with staff regarding a needed interim corrective action for staff involved in an incident; Discussed reporting incidents that violate Licensing Standards even if they are screened out from the Child Abuse Hotline. Management had several questions regarding what standards in the Minimum Licensing Standards apply to them; Further discussion will take place as soon as all needed parties are available.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Therapist blocked resident in corner from trying to fight peer. Resident began to push the therapist back so the BHA staff took the resident to the ground. BHA staff then attempted to put his hand around the resident’s neck and therapist intervened and removed the BHA staff away from resident. When asked later, the resident denied the BHA staff squeezed his hand around his neck. Witnesses reported staff did squeeze his hands around his neck.
    • Staff placed on Administrative Leave as of 8/20/21 and returned to work on 8/24/21 to receive de-escalation training. After specialist reviewed camera footage, a new hotline call was placed and accepted so the staff was placed on office duties with no direct or unsupervised contact with residents until investigation is completed. Unsubstantiated.  

PRLU or OLTC

Technical Assistance, Visit Compliance Report

  • Specialist discussed a report sent to the specialist involving a previous resident and staff member. Specialist is not prepared to leave a Licensing finding at this time due to the ongoing CACD investigation. Specialist reviewed 5 children’s records.
  • TA –
    • R904.1.h – The charts of 3 residents were noted to be missing required legal documents.
    • R110.9 – Specialist discussed with staff what reasonable cause means in mandated reporting and educated staff on expectations of staff to report any suspected child maltreatment or neglect to the Child Abuse Hotline immediately.
    • R905.17 – A restraint documented in a resident’s chart was noted to not have the names of staff involved in the restraint listed.
  • Licensing Specialist was asked to sit in on a meeting occurring with Tracie Schnider with Behavioral Health and Aging, who was there to discuss options for a deaf Arkansas DCFS foster child to be place at the facility. Specialist explained that the child shall not be admitted prior to the approval of the CWARB.

PRLU or OLTC

Notice of Incident

  • Staff Sexual Abuse
    • Alleged offender (previous staff) has been accused of having sexual intercourse with a previous resident during his time at the facility from Jan. – Mar. 2021. It is reported that the facility once reprimanded the employee for giving candy to this resident then conducted their own investigation into the sexual abuse allegations, but never called this report into the hotline, and that 2 other employees were aware of this situation and failed to report it.
    • Staff is no longer employed at the facility as of 3/31/21. On 8/17/21, Specialist received response from facility staff confirming they had knowledge of the accusation but did not find substantial evidence during their own investigation. Staff was terminated from employment on 3/31/21 after a no call no show. On 8/18/21, Specialist discussed with facility representatives the incident and appropriate mandated reporting. No further details.

Police Report

Sexual Assault First Degree

Caller from CAC stated that the child abuse hotline had received a report of alleged sexual assault that had taken place between a Juvenile and Staff member in February 2021. Juvenile has since returned home and Staff member was terminated in April 2021. Juvenile’s Mother found explicit photos in Juvenile’s phone from Staff. Mother advised hotline that Juvenile stated he and staff member had engaged in sexual intercourse while he was a patient at facility and she has been sending him money on cashapp.

PRLU or OLTC

Notice of Incident

  • Complaint
    • Specialist received an email reporting concerns about the facility. Individual reported she is aware of at least 2 times when a resident was assaulted by peers and 1 time she was sexually assaulted by peers. Individual also reported that “uncertified restraints happen all the time” and “*redacted* and *redacted* cover it up”. Individual stated she felt so strongly that wrongdoing by management was occurring that she left her job there.
    • *Redacted* of resident also reported multiple concerns regarding supervision at facility resulting in sexual activity and self-harm, the use of inappropriate restraint holds, resident able to use staff cell phones to make unauthorized calls, facility not following ICPC agreement regarding medications and incident reporting, objects found in facility to use for self-harm, and inappropriate comments from staff.
    • Specialist reviewed the chart of the resident named in the complaint to check for all correspondence documentation. No further details.  

PRLU or OLTC

Visit Compliance Report

  • No site visit conducted on this day.
  • Regs not correctable –
    • R907.2 – Incident report received on 7/14/21 from event that occurred regarding resident and a staff member shows staff did not provide the level of supervision, care,and treatment necessary to ensure the safety and well-being of each child at the facility.
  • TA –
    • P110.12 – Ensure that all child abuse hotlines made against the owner/operator, employee, volunteer, or other person in the child welfare agency are reported to the Licensing Unit by the next business day.

PRLU or OLTC

Notice of Incident

  • Other – Client Unsupervised
    • Staff left client on the unit alone for 18 minutes.
    • Staff member placed on administrative leave as of 7/14/21. Child Abuse Hotline was called, not accepted.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Staff can be seen on camera breaking up an altercation between peers and slamming resident to the ground.
    • Staff member was placed on administrative leave on 7/14/21. Child Abuse Hotline was called and accepted.

PRLU or OLTC

Visit Compliance Report

  • Specialist reviewed incident report/video footage involving a staff member and resident. Staff out of ratio and has one arm in cast.
  • Regs not correctable –
    • R905.9 – Staff member did not use minimal force, did not use proper restraint hold, and resident was not posing a risk to himself/others when restraint was initiated.
    • R907.3 – During the time of incident, the staff member can be seen out of ratio 1:7.
  • Regs out of compliance –
    • R912.4 – Bathrooms in A1, C1, and C2 need cleaned; Sinks were visibly dirty with grime and hair, toilet areas had visible urine on the ground and a strong odor. Staff were called to clean the restroom immediately.
    • R914.6 – Need new emergency evacuation diagram in the cafeteria and C1.

PRLU or OLTC

Notice of Incident

  • ER Visit – Abnormal ERG
    • Resident was taken to ER after a normal checkup at facility showed abnormal ERG results.

PRLU or OLTC

Notice of Incident

  • Injury – Accidental
    • Resident was playing outside and complained of calf pain to the staff on 7/2/21. Nursing staff did muscle stretches and gave the resident Ibuprofen. The resident then began to complain of pain again on 7/4/21 so an x-ray was ordered.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Resident was agitating a peer, and when resident ran to attack peer, staff extended his arm to stop him. Resident ran into staff’s arm, neck first. Resident began hitting staff several times so staff grabbed the resident by the shirt and flung him to the ground. Resident kicked and bit staff while on the ground. Staff then kicked the resident in the knee and proceeded to hold the resident firmly to the ground.
    • Staff was placed on suspension 7/2/21. Child Abuse Hotline was called and accepted.

PRLU or OLTC

Visit Compliance Report

  • Specialist visited facility to speak to resident about an injury to his nose. Resident disclosed that he had been doing tricks on a scooter during his rec time and sustained “road rash” from falling off the scooter while performing tricks. Minor injuries were taken care of by nursing staff. No licensing concerns observed related to this incident.
  • TA –
    • R713.5 – Minors expressed to Specialist that they did not want to use and did not like the texture of the sheets as they do not stay in place.
  • Regs not correctable –
    • R907.2 – Specialist viewed video footage from an incident involving staff member and his altercation and subsequent chokehold on a deaf resident. PRLU is determining this incident as: FOUNDED. PRLU is requested that staff shall not be involved in any restraints or discipline of residents pending the outcome of the investigation.

PRLU or OLTC

Notice of Incident

  • Injury by Staff
    • Staff was attacked by resident; Staff pushed resident away multiple times, pushed theresident into a chair, and used the resident’s arm to place the resident in a chokeholdfor approximately 5 minutes. Nurse assessment: No injuries or bruises.
    • Upon camera review, the allegation of physical abuse is substantiated. Additionally, the camera review reveals the staff member using an inappropriate hold to restrain thepatient. Staff member will be placed on a final written, restrained in TCI, put on a plan ofimprovement, and moved to nightshift. Staff member shall not be involved in anyrestraints or discipline pending outcome of investigation.
    • Child Abuse Hotline was called, not accepted.

Police Report

General Information Report

Caller stated that Juvenile began to attack Staff member and Staff pushed Juvenile off and away from him. When Juvenile tried to strike Staff again, Staff grabbed Juveniles arm and pulled it across his body. Juveniles arm pulled across his neck during the altercation. Risk Director at facility agreed that it was possibly an internal misconduct rather than a criminal matter.

PRLU or OLTC

Visit Compliance Report

  • Regs out of compliance –
    • R913.5 – In Room 156, a pillow was observed to be falling apart; Pillow was removed and thrown away during walkthrough.
    • R912.4 – In Room 165, the bathroom floor was wet from shower to edge of walls next to toilet.
    • R911.15.d – In Room 152, pants were found with long cord in waistband; Pants were removed during walkthrough.
  • Regs not correctable –
    • R907.2 – Specialist completed visit to follow up on incident where staff pushed a resident to floor with force causing bruising to the resident. Agency terminated staff afterwards.

PRLU or OLTC

Notice of Incident

  • Injury – Accidental by Peer
    • While playing flag football, peer hit client in the nose with his shoulder on accident.
    • X-ray results: Acute faint linear lucency in distal nasal bones compatible with acute nondisplaced fracture of distal nasal bones.

PRLU or OLTC

Notice of Incident

  •  Staff Abuse
    • Staff kicked client’s foot when she refused to remove her foot from blocking a door from closing. Video footage reserved; staff member placed on admin leave as of 06.02.21.
    • Notification late due to DRA being in building on 06.02.21.

PRLU or OLTC

Visit Compliance Report

  • Regs out of compliance –
    • R911.15.f – Strings/cords found on minors clothing in the following rooms: 177, 152, 156, & 202. Corrected 5.19.21.
  • TA –
    • R911.6 – Bathroom shower wall was peeling and in need of repair (repairs were in progress).

PRLU or OLTC

Notice of Incident

  • Improper Restraint
    • During classroom time, client did not complete his work, threw his paper down and attempted to walk out of the classroom. Support staff was called to the classroom. When staff arrived, client attempted to walk again but staff intervened. Shortly after,
      client attacked staff by punching her. Staff placed client in an improper restraint while attempting to hands on deescalate client. Client stated he could barely breathe, and staff was instructed to relieve him from the restraint by nursing.
    • Child Abuse Hotline was called and accepted. Staff placed on administrative leave 5.14.21 pending investigation. Video footage of incident was reviewed, and it was determined that staff initiated improper restraint hold on client, and another staff
      member stood by watching while failing to intervene and assist.