Little Creek Behavioral Health

• 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.

• 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.

•  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.

• 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.

• Improper Restraint
  • Staff was redirecting client to unit when client started to hit staff. Other staff intervened to assist. Staff used improper techniques to break up the fight. No one was injured or had any bruises. Staff members were placed on administrative leave due to improper
    techniques.
  • Child Abuse Hotline was called and accepted. Video footage was reviewed, and licensing complaint is found true on violation of regulation 907.2. Agency cited for violation of regulation 907.2.

• Maltreatment – Bullying, Uncleanliness, Lack of Structure
  • Client is bullied and beat up by other children daily and staff allow it to happen. Clienthas had injuries in the past from being bullied. Staff let the children do whatever they want. There had been only 1 janitor for the whole facility, but they resigned on 4.15.21.Over the last couple of months, the facility has been unclean and rapidly declining. Clear coat on showers is chipping & water is getting behind walls, resulting in mold and mildew. There is hair and feces on the walls and urine in the bathrooms everywhere, including the walls, which is left there for days. Staff do not make sure the childrenshower.
  • Child Abuse Hotline was called and accepted. No follow-up details.

• Resident Suicide Attempt. Resident did not respond after staff heard coughing from behind her closed bedroom door. Resident ran in room and attempted to take clothing items from around her peer’s neck.

• Resident held down on bed by two staff members after being aggressive. Staff placed on admin leave.

• Deaf resident hit with pen by staff to get their attention.

• Resident to ER and then hospitalized for being lethargic and hypotensive. Diagnosis was severe constipation and resident was still hospitalized on 02/26/21 with a possible discharge date of 03/01/21.

• Resident discovered with cellular device. Investigation revealed staff member bought resident under garments.
• Staff member terminated as of 2/25/21. Child Abuse Hotline was called but not accepted.

• Resident transported to ER and spent 2 days in hospital for lithium toxicity