Disability Rights Arkansas

Millcreek Behavioral Health / Habilitation Center, Inc.

Location: Fordyce, AR

Population Served: Youth ages 6-17

# of residents per unit: Up to 20 Residents per room: 2-3

Capacity: 162 (111 Arkansas Medicaid PRTF beds, 51 Residential beds used for out-of-state resident PRTF placement or AR contract beds).

Contact with family (Calls and visit schedule): Family visits vary on a case-by-case basis. Phone Calls are allowed on 4 days of each week and are limited to 10 minutes unless otherwise specified.

Restraint utilized? Yes Chemical Restraint utilized? Yes Seclusion utilized? Yes

Treatment Components:

Clinical Director - LPC

Therapists: 8 full-time therapists (LPC-S, 5 LPC, 1 LCSW, 1 LMSW)

Treatment modalities offered: 1 EMDR, TF-CBT

# of individual therapy sessions/week: 1

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

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Police Report

Second Degree Escape

At approximately 12:15pm, Nurse provided officers with description of missing juvenile and advised that the last time staff saw him, he was running into a wooded area. On 06/26/22 at approximately 8:38am, officer was advised that the juvenile was located. The juvenile was transported to the police department and the facility made arrangements to pick him up.

PRLU or OLTC

Complaint Survey

  • Complaint #AR00028297 was unsubstantiated, with deficiencies cited.
  • Regs out of compliance –
    • N 156 – Facility failed to ensure a physician’s order for a physical was signed for 1 client.
    • N 178 – Facility failed to ensure guardians were notified of the use of a physical restraint for 1 client.
    • N 209 – Facility failed to ensure a serious occurrence was reported to the required agencies and the report was maintained in the medical record for 1 client who sustained an injury requiring outside medical care.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client reported to a nurse that he had been grabbed by a staff member. Client stated that he started banging his head on the wall because he was mad about a game, and staff grabbed him to assist him to his room. Nursing report indicated a bruised area, approx. 4cm. When interviewed by Risk Management, client stated he was being self-injurious, and he felt that staff was not trying to harm him.
    • Child Abuse Hotline was called, not accepted. Staff will not work in proximity of client. Licensing follow-up on 6/8/22: Facility visited, and client interviewed. Licensing is not prepared to make a finding at this time. Risk Management reported staff will be in-service retrained in TCI.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client stated, “they slam me down really hard to the ground during restraints.” Client stated that staff has threatened to “drop” him multiple times. Client stated he was last slammed down about 3 weeks prior. Staff involved unknown.
    • Child Abuse Hotline was called and accepted. Upon client interview, client stated that he was not thrown by any staff member and was unaware of any events that could have been related to this claim. Licensing follow-up on 6/8/22: Facility visited, and client interviewed. Client stated he didn’t know why the report was made and no staff had hurt or threatened to hurt him.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client stated staff member put him in a chokehold. Nurse assessment: Petechia to front and back of shoulders, red scratches to left rib area, redness to left side of back, 2 small bruises to upper left chest, c/o wrist hurting. Tylenol administered.
    • Child Abuse Hotline was called and accepted. Staff placed on administrative leave. Licensing follow-up on 6/8/22: Facility visited, and client interviewed. Client stated staff had pushed him to the ground after he “cussed” and “pushed” staff. Client stated it did not seem that staff was doing this to hurt him and stated the hold staff was performing did not hurt him.

PRLU or OLTC

Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Facility visited from 8:30am – 9:30am. Census: 162. MARs checked for multiple residents. No licensing concerns noted during visit.

PRLU or OLTC

Children's Records Review, Personnel Record Review, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Facility visited from 9:30am – 1:00pm. Records reviewed for 10 residents and 10 staff members.
  • Regs not correctable –
    • R904.1.h – Two clients missing legal documents e.g., Birth Certificate and Social Security Card. A request form or correspondence indicating these items had been requested was not present in the files. Admissions staff indicated these were out-of-state clients and that the requests for these documents were sent in the form of an email. Risk Management indicated that all emails are deleted after 30 days. Moving forward, when an email is sent requesting these documents, it will be printed off and placed in the file.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client reported she was asleep in bed and woke up to her roommate kissing her. Client stated that peer digitally penetrated her vagina. Client stated she went back to sleep and did not immediately report this to staff. Peer stated the events did not occur, and that a staff member was positioned outside her open bedroom door throughout the evening.
    • Child Abuse Hotline was called, not accepted. Licensing follow-up on 5/18: Facility visited, no evidence to refute nor confirm allegation.

Police Report

Second Degree Escape

At approximately 1528 hours, officer was dispatched for 2 runaway juveniles. Staff reported they ran away at about 1458 hours. Officer attempted to locate but was unsuccessful. On 5/7/22, officer was advised that facility had the 2 juveniles back in their care.

PRLU or OLTC

Notice of Incident

  • Maltreatment (1)
    • Client reported to a staff member that a peer had pulled his pants down and sucked his penis while playing Hide and Seek. Peer denied incident and stated client was lying to get him in trouble.
    • Child Abuse Hotline was called, not accepted. Both clients were placed on Close Observation (already reside in separate rooms) and an internal investigation is being conducted. Licensing follow-up on 5/11/22: Camera footage reviewed, and client/peer interviewed. Peer stated he plays Hide and Seek often and when asked where staff were he stated, “they don’t pay attention.” Client stated again that peer had sucked his “privates.” No definitive evidence to yield licensing concerns.

PRLU or OLTC

Notice of Incident

  • Maltreatment (2)
    • Facility was notified of an outside report made to the Child Abuse Hotline. Allegation: Complainant picked up client from facility and saw various bruises on his shoulder, back, shoulder blades, neck, and forearms. All bruises were in various stages of healing. Client stated that other children were holding him down and punching him, and that staff knew and told him not to tell otherwise he would get his phone privileges taken away.
    • Child Abuse Hotline was called and accepted. An internal investigation is being conducted.

PRLU or OLTC

Notice of Incident

  • ER Visit (Accidental Injury)
    • Client slipped and fell while playing basketball outside. Client was sent to ER for x-ray due to his wrist hurting. X-ray results: Fracture to right wrist. Client has brace in place to right wrist/hand area.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client disclosed that previously, another child hit him, and a staff member smacked him with an open hand on his face a couple of weeks ago. Client has still not received eyeglasses (requested on 11/2021) and is on waiting list. Client’s hygiene is inadequate, his clothes were dirty, he was disheveled, and he seemed to be wearing the same clothes for multiple days. Client was asked if he bathes and he stated “no, because they do not make him.”
    • Child Abuse Hotline was called and accepted, unsubstantiated. Licensing follow-up on 4/22/22: Clients (3) were interviewed and all reported access to a shower, clean clothes, feeling safe at Millcreek, and how to report to staff if they feel unsafe. Client received his glasses and was wearing them. Client was showered and had clean clothes on. Client’s therapist reported that client frequently refuses to shower or change clothes.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client alleged that staff member punched him in the jaw while being placed into a physical restraint. Internal Investigation: Multiple staff were interviewed, and no report corroborates the allegation. There were no resident witnesses. In client’s incident debriefing, client stated he didn’t want a witness statement because “the staff did not do anything to me.” Client’s initial discussion with therapist indicates discrepancies, as he first indicated that another staff member was the one that punched him.  
    • Child Abuse Hotline was called, not accepted. Alleged staff member remains on leave until completing in-service Therapeutic Crisis Intervention at which time he will be rescheduled for employment, and client/staff interaction will be limited to basketball events. Licensing follow-up on 4/19: Reviewed witness statements and interviewed client. There is no definitive evidence to support that staff struck client.

Medicaid Inspection of Care

Inspection of Care Report

  • Included: IOC
  • No deficiencies noted.

Police Report

Radio Log

ICF – Staff called for update on missing juveniles and officer stated they had not received a call (staff called Dallas County); Staff stated that 2 juveniles had been missing since about 9:30pm. Juveniles were spotted on morning of 4/10 but not found. At 1240 hours on 4/10, the missing juveniles were found and back at Millcreek.

Police Report

Assault Second Degree

ICF – Officer served an affidavit warrant for Assault 2nd Degree with a bond amount of $570.00 on staff member and issued court date.

Police Report

Battery Third Degree, Radio Log

ICF – Caller stated that on 3/27, resident had wanted to call his aunt and while staff was trying to find the phone number, resident began fighting him. Caller stated the staff member had struck the resident in the head during the fight; Child Abuse Hotline was called but refused the report since the resident was 18y/o.

Police Report

Radio Log

Dispatch reported prank calls coming from facility address; Officer called and spoke with facility staff who stated they would take care of it.

Police Report

Radio Log, Third Degree Escape

Staff reported 3 juveniles escaped facility (Eagle Hall). Dispatch advised that while on the phone, the 3 juveniles were apprehended and back in Millcreek custody.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Licensing received report alleging that unknown staff members allowed client to be struck in the head while showering. Another report alleged that a staff member flipped client’s mattress over and pushed personal belongings off his bed. Client was interviewed by DHS investigator, stating he was kicked in the back during an interaction in his classroom, identifying his teacher as the staff member who kicked him. Nurse evaluation: Reddened area 1” diameter to lower back on left side. Per DHS investigator, staff accused in the incidents were not being required to be placed on administrative leave. “Corrective actions will be taken pending the results of internal and external investigations.”
    • Child Abuse Hotline was called and accepted. Specialist visited facility on 3/16/22 and reviewed witness statements. Regarding the incident in the shower, client stated staff did nothing about it but could not state whether staff was a man or woman. Alleged staff member involved in flipping client’s mattress over could not be reached by phone. Teacher was interviewed regarding kicking the client in the back: Teacher stated that she had stood by client to keep door from banging while client kicked it (laying on floor), and her foot might have touched client, but stated she did not kick client in any way. Interim Corrective Action: Staff member can work but not around children pending further investigation. No citations.

PRLU or OLTC

Visit Compliance Report

  • Census: 18. Buildings and grounds conducted, and MARs checked for 5 clients.
  • TA –
    • R911.15.f – Tie strings found in shorts. House staff advised to search each room and remove all clothing items that had drawstrings.

PRLU or OLTC

Notice of Incident

  • ER Visit (Accidental Injury)
    • Client was playing recreational game when he fell and hurt his arm. Client was taken to Dallas Co. ER, then to ACH for treatment. AR Children’s Hospital: Closed fracture of distal end of left radius, unspecified fracture morphology. Closed reduction performed under deep sedation. Agency will continue to monitor client.

Police Report

Radio Log

Staff requested officer to Millcreek (Magnolia Hall) due to juveniles hitting staff and 3 juveniles missing from facility. Upon officers arrival, there was no disturbance in halls and they found the missing boys.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Alleged staff member aggressively yelled at client and intentionally hit him on his head 4 times (unknown what staff used to hit client). No injuries reported. There is a voice recording of the staff member yelling at client.
    • Child Abuse Hotline was called and accepted. Staff member was placed on administrative leave pending investigation. Specialist visited facility on 3/8/22 and reviewed video footage from 8:00-8:45pm on 3/2/22, which does not show staff member hitting any children. It does show staff member point her finger and appear to yell (no audio). Client and staff statements were reviewed. Staff denied hitting client but admits she yelled at client to go to bed. Two other clients were interviewed and did not indicate staff had ever hit them. Client involved indicated staff member hits and slaps him in the back of his head and grabs his neck. When asked if staff ever called the client names, client stated “FB, MF, SOB”. Client is believable when asked to describe how staff hits him. Risk Management states that staff member has been involved in a previous incident at facility before and stated that staff member is on leave and to be terminated. Facility cited and staff involved in incident employment terminated.