- Included: IOC (revised), Reconsideration Determination Letter
- Multiple deficiencies noted. Plan of Correction required to be completed within 30 days.
Medicaid Inspection of Care
On-Site Inspection
PRLU or OLTC
Notice of Incident
- Suicide Attempt
- Client became upset and went to her room; Client remained in her room while unit left for cafeteria. Client took her clothes off, found a phone charge cord in the hallway and tied it around her neck. She stated she did this because she heard a voice telling her to. Upon noticing she was not with the group, staff came back to unit to discover her condition in the bedroom. Client was placed on suicide prevention precautions.
- Staff members involved were placed on administrative leave as an investigation was conducted. In-services are being completed campus-wide in relation to head counts, documentation, informational handoffs, staff to patient ratio/supervision, cell phone usage/security. Child Abuse Hotline was called, not accepted. No video footage available of the incident.
PRLU or OLTC
Complaint Survey
Complaint #AR00027235 unsubstantiated.
PRLU or OLTC
Notice of Incident
- Restraint Injury
- After client attempted to hit staff with a loose board from the playground equipment, client was placed in a restraint. Client complained of pain to left ankle, originally stating that he twisted his ankle when he fell, and later stated that staff rolled over his ankle while placing him in a restraint. Client stated that he is not sure what happened, but he didn’t think that staff member intentionally hurt him. Client was sent to ER for X-ray: Closed fracture to left navicular bone. Patient placed in short leg cast.
- After specialist follow-up, facility staff stated that the playground equipment is old and is more than likely going to be removed. Names of staff involved in incident were provided. No camera footage available. Specialist followed up on equipment removal via email.
Police Report
Radio Log, Second Degree Escape
Officers were dispatched for 3 runaway Juveniles from facility. Upon arrival, Officer saw 2 females on the ground with 2 staff members restraining them. J1 was fighting with staff member trying to get free. Officer placed both Juveniles in handcuffs and in patrol unit. J1 stated staff member choked her; Officer advised staff member did not. Officer states staff had J1s arms crossed on her chest and restraining them down on her chest to keep her from escaping again. No marks found on J1. Officer transported the 2 Juveniles back to facility.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Client reported that after jumping into an argument between his peers, staff pushed him, so he pushed staff back. Client stated that staff grabbed him by the neck and slammed him to the floor which led to a restraint joined by the rest of the staff members. Client stated that the staff threatened that he would have him moved to another unit so that other patients would jump him.
- Staff member was put on leave pending the investigation. Child Abuse Hotline was called and accepted, unfounded. Specialist requested video footage and facility stated that it was saved for review. On 10/14/21, Specialist was advised that staff is still on leave/working in another capacity. No further follow-up details.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Client stated that staff member squeezed her in between 2 chairs and that she cried out that she couldn’t breathe. Client stated that staff told her to go to her room and staff came to her room and choked her. Client noted to have slight bruise on left inner foot with small swelling noted.
- Staff placed on leave pending investigation. Staff remains on leave as of 10/14/21. Child Abuse Hotline called and accepted, unfounded. There is no video footage of the incident. As of 10/14/21, staff advised they were waiting for CACD to finish their investigation.
Police Report
Radio Log, Second Degree Escape, Theft
Officer was dispatched to facility at approximately 2010 hours for 3 runaway juveniles. Staff stated the juveniles ran into the woods. At approximately 2118 hours, Officer was advised that staff with Millcreek stated they had all 3 juveniles back at the facility. Nurse later reported to Officer that individual had called stating her mother’s phone had pinged at Millcreek, and staff then found the phone on one of the runaway juveniles.
PRLU or OLTC
Visit Compliance Report
- Regs out of compliance –
- R911.6 – Plug cover in Penguin Hall day room and shower were inoperable; Baseboard in Flamingo Hall needs to be replaced; Shower inoperable in Zebra Hall; Replace wet and missing ceiling tiles in Deerfield; Hole in bedroom wall in Magnolia Hall; Switch covers loose in rooms 6 and 2 in Rock Hill; Showerhead loose in bathroom #2 and inoperable in bathroom #3 in Pine Ridge.
- R914.4 – Rock Hill room #3 smoke detector inoperable.
- R911.15.f – Drawstrings and/or shoestrings were present in Zebra Hall room, Tiger Hall rooms, and Rock Hill room.
- R912.2 – Only 1 out of 3 showers operable for 16 kids.
- R9095.4.h – Licensing staff heard a female staff member in Tiger Hall yelling at patient and this led to the escalation of the situation. Staff should be retrained on this standard.
- R910.1 – Outbuildings on the grounds near cottages need to be secured.
- R912.6 – Paper towel holders would not close and were empty at the boy’s school.
- R908.9 – While checking the MAR at nurse’s station for Eagle, Kangaroo, and Tiger wing, MAR was checked for 5 children and proof of meds being given was not present on the 14th of August for 3 of the kids. The nurse was not aware of why this was not documented.
Police Report
Radio Log, Second Degree Escape
Officer was dispatched at approximately 2015 hours for Juvenile that ran from facility. Staff stated that at approximately 7:25pm, Juvenile slammed door and took off running from facility. At approximately 2135 hours, Officer was patrolling area when Millcreek staff flagged him down and advised they had found the Juvenile and were bringing him back to facility. Officer checked on Juvenile, who stated he ran away because he wanted to talk to someone.
Police Report
Battery Third Degree
Caller stated her daughter had been bullied at Millcreek since arriving there on 8/9/21. Juvenile stated that her roommate grabbed both her arms and pulled her off the bed. Juvenile also stated she did an incident report but no one followed up or did anything about it. Juvenile also stated a group of girls came to her yelling that she had chores to do and if she didn’t no one was going to the talent show. Juvenile stated she hasn’t been sleeping or eating, and that she didn’t want to be at Millcreek anymore.
Police Report
Sexual Assault
Staff at Dallas County Medical Center advised 18 yr old female was sexually assaulted from Millcreek. No other info.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Statement from client: Staff stated “Girl, I’ll beat the fuck out of you – you better know who you are fucking with.” After a few more statements from staff, client stated staff kicked her on the head and stabbed her with a pen/pencil twice in the hand. Client stated other staff threw her dinner away and threw her breakfast away the next morning. That same staff member told her to make the pen/pencil situation with other staff member sound like an accident. Nurse noted sore to left hand and pencil tip blood blister area on finger. Client reports that she had a knot on center of forehead and only complained of it being tender now.
- Facility advised that staff were put on leave pending an investigation. Child Abuse Hotline was called and accepted, unsubstantiated. Facility staff stated no video footage was available of incident.
Police Report
Radio Log, Second Degree Escape
At approximately 1556 hours, officer was dispatched for several kids running away from facility. While entering subjects in ACIC, 2 Juveniles returned to facility. Officer located 3 other kids walking down Highway 79 and escorted them back to Millcreek. All subjects were back in custody of Millcreek care takers.
PRLU or OLTC
Notice of Incident
- Peer Altercation
- Client and peer were exchanging words when peer picked up a can of disinfectant spray and threw it at client, hitting him on the head. Client received 1” laceration to left upper head. Client transferred to ER and returned with 3 staples to laceration.
- Specialist followed up for video footage, and facility reported they had saved the footage. No further follow-up details.
PRLU or OLTC
Notice of Incident
- Staff Abuse
- When client started fighting peer for no apparent reason, staff separated clients. Client had small laceration to the left side of his lower lip with blood oozing. Client was sent to ER where he received 3 sutures. On 8/9/21, client filled out grievance form stating that after staff broke up the altercation, staff was too rough and threw client against the wall causing his lip to bust, resulting in 3 stitches.
- Staff member was put on administrative leave pending outcome of the investigation as of 8/13/21 due to the grievance that was filed following the incident. No video was available in the area where the incident took place. As of 8/23/21, staff member was still on leave. Investigation still pending.
Police Report
Radio Log, Welfare Check
Police responded for a welfare check on Juvenile requested by guardian. Upon arrival, Unit Supervisor stated they had been having problems with the phone’s services. Juvenile stated he was fine and that he had been trying to call his mother but the phones “are broke”.
PRLU or OLTC
Visit Compliance Report
- A visit was conducted to discuss residential/PRTF beds with staff.
- Regs out of compliance –
- R911.6 – Walls with holes needing repaired, baseboard shoe needs to be replaced or reattached to the wall (Rock Hill), door leading to day area has broken lock (Eagle Hall), viewed leaking water fountain onto the floor (Tiger Hall); “Part of 911.6 was corrected during the visit”.
- TA –
- R911.15.f – Specialist viewed client at Pebble Creek cottage with shoestrings in his shoes (removed during visit).
Police Report
Radio Log, Second Degree Escape
Police dispatched at approximately 0008 hours for 2 escapees. Nurse stated that the 2 Juveniles were last seen at 0000 hours running towards the woods. At approximately 0252 hours, police located both Juveniles inside Exxon and transported them back to Millcreek.
PRLU or OLTC
Notice of Incident
- Other – Peer Sexual Abuse
- Client stated when he went to bed, his roommate woke him up by touching him inappropriately. Client stated he tried to tell his roommate no multiple times and his roommate started pulling his hair. Client stated that, “He then pulled out his dick and put it in my mouth.” Client stated he tried to fight back, but failed, and another patient walked in on them. Peer confirmed the incident.
- Client was evaluated by the nurse and admitted to giving oral sex; He denied injuries or ejaculation to mouth area. Child Abuse Hotline was called and accepted. Patients were moved to different rooms.
Police Report
Battery First Degree, Radio Log
Police dispatched to Dallas County Medical Center in reference to abuse of Juvenile. Juvenile from Millcreek stated he was pushed down by staff member, causing arm injury (fracture). Juvenile to be transported to ACH for treatment. Juvenile stated staff member was mad due to him being out the door and pushed him back in the room. Police and Millcreek staff viewed video footage. Child Abuse Hotline # 2099453.
PRLU or OLTC
Notice of Incident
- Injury – Self-inflicted
- Client stated he got mad and punched a door, hurting his hand; Nurse evaluated, and client was transferred to ER.
- Radiology report: Mildly displaced dorsal hamate fracture.
Police Report
Sexual Assault Fourth Degree
Staff stated that on 7/13/21 they had caught 2 Juveniles having consensual sex. Staff stated she had called the Child Abuse Hotline to report the incident, but it was not accepted.
PRLU or OLTC
Notice of Incident
- Injury by Staff – Fracture
- On day of incident, client initially reported to nurse that he fell and hurt his arm. The next day, 7/16/21, the client was sent to the ER for evaluation of his arm. Client reported to hospital staff he was pushed by staff member at facility.
- X-ray results: Nondisplaced acute transverse fracture to left humerus. Staff member placed on leave pending investigation. Child Abuse Hotline was called and accepted.
Police Report
Possible Runaway, Radio Log
Nurse stated they have a Juvenile that eloped from the play area about 10 minutes prior. Nurse reported a few minutes later that they had located the missing girl.