- Elopement
- Client eloped from facility by climbing fence while he was outside playing basketball. Local police were notified of elopement. No follow-up details.
PRLU or OLTC
Notice of Incident
PRLU or OLTC
Visit Compliance Report
- Census: 15. Buildings and grounds walkthrough conducted (gym not able to be viewed due to ice/snow accumulation blocking the entrance). MARs reviewed for 3 residents.
- TA –
- R910.1 – Please ensure ice/snow accumulation is removed on the walkway and in front of the gym door to ensure the safety of residents.
PRLU or OLTC
Children's Records Review, Visit Compliance Report
- Specialist reviewed 5 children’s records.
- TA –
- R904.1.n – No nightly visual observations are documented in the chart for November – December 2021. Ensure these are uploaded in resident’s EMR.
- R904.1.m – No daily behavioral observations are documented in the chart for November – December 2021. Ensure these are uploaded in resident’s EMR.
PRLU or OLTC
Notice of Incident
- Arrest
- Client became aggressive/assaultive towards staff and wouldn’t respond to disengagement techniques. Police were called and the client was arrested.
- Specialist followed up on 12/15; Staff confirmed that a review was conducted, and no issues were found. The client has been discharged from the facility.
Police Report
Battery Third Degree
Staff stated juvenile had been aggressive and twisted her arm and scratched it; When other staff members intervened, he acted like he would punch her. Officer was advised the jail was full and not accepting anymore prisoners. Staff stated she would like a report made.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Client was refusing to follow prompts from staff member while being escorted back to his room. Client reportedly fell backwards onto staff member and was caught under the arms by staff. Staff member then picked client up under his arms and transported him down the hallway.
- Child Abuse Hotline was called and accepted. Staff placed on suspension pending the results of the investigation. Specialist emailed staff on 11/24/21: Staff confirmed the facility will update the ICA and ensure staff member has no direct or unsupervised contact with children until conclusion of investigation. Licensing Specialist visited facility and discussed the incident, reviewed camera footage, received nursing notes and written incident reports. Licensing was notified that staff member resigned from their position.
PRLU or OLTC
Notice of Incident
- ER Visit
- Client was transported to ER after punching a dresser multiple times and a window. Client complained of pain in his right hand. No follow-up details.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Staff witnesses reported to management that staff member used excessive force on client as client was acting out aggressively.
- Child Abuse Hotline was called and accepted. Staff was suspended pending the results of the investigation. Specialist emailed staff to confirm the report was accepted for investigation and received a confirmation number. Specialist visited facility on 11/19/21 and discussed the incident, reviewed camera footage, obtained nursing notes and witness statements previously written on the incident.
PRLU or OLTC
Visit Compliance Report
- Specialist discussed incident and reviewed video footage in which resident was assaulted by 2 peers. Footage shows ratio 6 residents/1 staff. Staff responded quickly and nurse assessed within 3 minutes of incident. Resident will move to a different bedroom (1 peer was his roommate) and will be on peer restriction to ensure his safety.
- Specialist discussed another incident in which resident attempted to elope, threatened staff with screws, self-harmed with a pencil, then attempted to hang himself with socks tied together and onto a light fixture in his bedroom. Resident was placed on suicide precautions and assessed using the Columbia Suicide Severity rating scale. It is unknown where screws came from, but staff will continue to look into this.
PRLU or OLTC
Notice of Incident
- ER Visit
- Client was assaulted by two peers while lying in his bed. Both punched resident multiple times in the face. After staff removed the peers and were transporting client to the nurse’s station, one of the peers punched client again in the face. Client was taken to ER.
- Specialist visited facility to view video footage; Staff to resident ratio is 1:6.
PRLU or OLTC
Notice of Incident
- Suicide Attempt
- Client attempted to elope from facility from an unlocked door when staff intervened. Client began threatening staff with screws that were then taken from the resident. Client then got a pencil from a peer and proceeded to self-harm with it until staff were able to obtain the pencil. Client then made a rope of socks and attempted to tie them to the light fixture and his neck; Staff intervened.
- Client was assessed by a nurse using the Columbia Suicide Rating Scale and determined not to need acute placement. Staff was unaware of how the resident was able to access screws on the unit but will have staff look at the unit and attempt to have the resident disclose how he was able to find screws.
Police Report
Assault Second Degree
Officer was contacted by Dacus RTC on 11/11/21 in reference to an assault that had already occurred. Officer arrived on scene to collect witness statements and spoke to the victim. No other info.
PRLU or OLTC
Notice of Incident
- X-ray (Peer Altercation)
- Client was in an altercation with peer and injured his hand punching peer. Client received X-ray.
- No follow-up details.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Client refused to exit bedroom when 2 staff members were prompting him to leave. Staff entered the client’s room and forcibly shoved client from the room causing him to fall and sustain an abrasion to his forearm.
- Staff member was terminated from employment on 10/20/21. Other staff member involved was placed on suspension pending the results of the investigation as of 10/22/21.
- Child Abuse Hotline was called and accepted. Facility reported the resident was shoved and video footage was available of the incident. Video is unclear whether the second staff member was also pushing resident or trying to grab resident. The investigator stated no investigation was being done on the second staff member. Specialist requested facility retrain staff member on appropriate restraint holds and mandated reporting. Trainings were given to staff on 10/22/21.
PRLU or OLTC
Validation Survey
A 5-year Validation Survey was conducted from 10/11/21 through 10/14/21. No deficiencies cited during survey.
Medicaid Inspection of Care
On-Site Inspection
- Included: IOC
- Multiple deficiencies noted. Plan of Correction required to be completed within 30 days.
PRLU or OLTC
Visit Compliance Report
- Licensing Specialist viewed buildings and grounds, and MARs for residents. The current census is 23.
- TA –
- R110.11 – Specialist discussed with staff that a log of all hotline calls should be maintained by facility. There is no log for calls being maintained at this time.
PRLU or OLTC
Notice of Incident
- ER Visit (Peer Altercation)
- Client called peer a name while outside playing basketball; Peer punched client in the face 2 times.
- Client was taken to ER due to laceration above his left eye and a scratch/bruising under the left eye. Specialist emailed facility to determine ratio at time of incident, if residents are now peer restricted, and if the aggressor was placed on assault precautions. No further details.
PRLU or OLTC
Notice of Incident
- Self-Harm
- Client was in restroom when staff heard banging on the walls; Client did not respond so staff entered to find the resident punching and kicking the wall. Client then tied sweatshirt around his neck in attempt to self-harm. Staff removed the shirt and client was placed in restraint hold.
- Specialist followed up on injury “wording” (“no new injuries were observed”) in report; Facility states that the resident did not have any previous injuries.
PRLU or OLTC
Notice of Incident
- X-ray (Peer Altercation)
- Client was in altercation with peer and sustained an injury to his hand. X-ray ordered.
- No follow-up details regarding the incident.
PRLU or OLTC
Visit Compliance Report
- Specialist reviewed 5 personnel records; Visit conducted at an off-site location due to current Covid-19 outbreak at Bono location.
- Regs out of compliance –
- R105.15.g – Facility will provide specialist with a new job description for staff member who has changed job positions in 2021.
- TA –
- R105.15.f – Please ensure you obtain documentation that all applicable employees are informed they are mandated reporters and have been given all required information to make a report.
- R105.13 – Discussed current process of documenting annual training of staff as they currently do not show the amount of hours staff is trained on each topic. Additionally, current list does not show which trainings are “psychiatric specific.” Licensing Specialist will request further clarification on what trainings are considered “psychiatric specific” from PRLU management and report back to the facility.
- Regs not correctable –
- R105.8 – Staff member received 19 hours of continuing education from June 2020 – June 2021. Required training hours are 30 per year.
PRLU or OLTC
Notice of Incident
- ER Visit (Self-Harm)
- Client became upset and refused to follow instructions from staff when he was threatening to harm a peer. Client was transitioned into hallway to calm down when he began punching the door. Client was taken to ER for evaluation.
- No follow-up details regarding the incident.
PRLU or OLTC
Visit Compliance Report
- No site visit conducted on this day. Specialist spoke with CEO and discussed incident (7/23/21) regarding resident assaulting two staff members and then being taken into police custody. Licensing Complaint for standard R110.17 is FOUNDED.
- No site visit conducted on this day. Specialist spoke with CEO and discussed incident (8/3/21) regarding resident being found in his room with a pillowcase tied around his neck. Licensing Complaint for standard R110.17 is FOUNDED.
- Regs not correctable –
- R110.17 – Incident occurred on 7/23/21 but was not reported to licensing until 9/1/21.
- R110.17 – Incident occurred on 8/03/21 but was not reported to licensing until 9/1/21.
PRLU or OLTC
Notice of Incident
- ER Visit (Basketball Injury)
- Client was taken to ER after getting scratched in both eyes while playing basketball with a peer.
- Specialist followed up to confirm date of incident, since it was received on 10/12/21.
PRLU or OLTC
Notice of Incident
- Suicide Attempt
- Staff found client on bedroom floor with pillowcase tied around his neck; Peer was also on the floor attempting to remove the pillowcase. Staff removed pillowcase and called for assistance from nurse.
- Specialist emailed facility for follow-up actions and video footage. No further follow-up details.