- 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
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.
PRLU or OLTC
Notice of Incident
- Suicide Attempt
- Staff was notified that client was no longer in bed; Staff located client on the floor with a pillowcase tied around client’s neck. Staff attempted to take the case off and received assistance from another staff member to remove it.
- The pillowcases were removed from client’s room for a time, he was assessed by a nurse and the physician ordered suicide precautions which remained in place from 8/3 – 8/13. This included line of sight observation and client was placed on a focus system to adjust his behavioral interventions to specifically address the issue. Client met with therapist on 8/4.
PRLU or OLTC
Notice of Incident
- X-ray (Self-Harm)
- Client punched a wall after becoming upset by a game of basketball. Client was sent for an X-ray.
- Reported to specialist on 10/28/21: The previous management was not reporting the incidents to the Licensing Unit which has since changed so the facility has been going through old reports to send any missed incident reports to the Licensing Specialist. The agency has already been cited for late reporting and staff educated on what should be reported moving forward.
Police Report
Assault Third Degree
On 7/23/21, Staff stated Juvenile became verbally agressive and then made a statement that he was going to run. 2 Staff members attempted to restrain him, and resident started hitting and head butted both staff members causing their lips to bleed. Juvenile was placed in custody and transported to Craighead County Detention Center.
PRLU or OLTC
Notice of Incident
- Arrest
- Client became upset with staff and began to push staff, yelling and cussing. Client stated he would run away, so staff grabbed client and took him inside the building. Client headbutted staff so he was put in a restraint hold. Client broke free from hold and hit staff in the face with his head. Client was placed back into a restraint hold and a chemical restraint was given to client. Police were notified and client was arrested.
- Child Abuse Hotline was called and accepted, unsubstantiated. Client was taken into custody and placed at the JDC for a few days, but then returned to facility. Facility will be cited for the late report to the Licensing Unit. Upon video footage review, incident showed that staff used force against child.
PRLU or OLTC
Visit Compliance Report
- Completed walkthrough, reviewed 5 MARs reports. Licensing encourages the agency to seek guidance from the Arkansas Department of Health on how to address positive cases of Covid-19 in congregate settings; Ensure all positive cases are reported to the Licensing Specialist by the next business day of the positive result.
- Regs out of compliance –
- R914.6 – Ensure fire escape route diagram is placed in the cafeteria easily viewed by residents.
PRLU or OLTC
Visit Compliance Report
- Regs not correctable –
- R904.1.h – Legal documents or documented attempts to receive them were not noted in the cart for client within 30 days of admission.
- Completed walkthrough and reviewed 5 children’s records.
Police Report
Assault Second Degree
Staff stated that Juveniles 1&2 had hit Juvenile 3 in the head. Juveniles 1&2 stated they got upset with Juvenile 3 for threatening to hit staff and hit him with their fist. Staff stated they would keep them separated. The next day, Grandmother of Juvenile 3 stated she wanted to make a report and that she would be removing him from the facility as she doesn’t feel it is safe.
PRLU or OLTC
Notice of Incident
- Peer Sexual Activity
- Resident forcefully gave hickeys to peer on her upper chest against her will.
- ICA: Staff will do in service with all staff that when they need to leave their assigned work area that they will have someone observe their clients. No follow-up details.
PRLU or OLTC
Notice of Incident
- Injury
- Client was running and tripped over foot of another resident; He fell and hit his left temple on the ground. There was swelling and bruising, so he was transported to Urgent Care to rule out fracture and concussion (both ruled out by physician); There was 1 staff member with 5 residents at the time of incident. No follow-up details.
PRLU or OLTC
Personnel Record Review, Visit Compliance Report
- Reviewed 10 personnel records & completed walkthrough, no regs noted out of compliance.
- Regs not correctable –
- R105.8 – Staff member only completed 20 hours of training for the 2020 year.
PRLU or OLTC
Visit Compliance Report
- Completed walkthrough of buildings and grounds. Census = 20 boys. Gym is currently closed due to construction.
- Specialist could not review personnel records because they are located in Little Rock. Will coordinate with human resources in LR to schedule a date to view records at Dacus next quarter.
Police Report
Assault Second Degree, Reckless Conduct Creates Risk of Physical Injury
Staff stated Juvenile was acting up and when Staff tried to get him to stop, Juvenile punched another child in the face and turned on her (Staff) when another Staff member came to help, he hit the other Staff member while the were trying to get him to stop. Staff wanted Juvenile prosecuted; Officer placed Juvenile in handcuffs and transported him to detention center.