Licensing Specialist: Clayton DeBoer.
Facility visited and random video reviewed of cottages during evening hours. No licensing concerns noted.
PRLU or OLTC
Visit Compliance Report
PRLU or OLTC
Notice of Incident, Self-Harm
Client was sent out for an outpatient X-ray after complaining of pain to her hand after punching on the punching bag during recreation time the previous evening. No fractures were found. Client was returned to Millcreek without any restrictions. No licensing concerns noted from this report.
PRLU or OLTC
Notice of Incident, Peer Altercation, Visit Compliance Report
Client was sent out for an emergency dental appointment after a physical confrontation with a peer, resulting in one tooth being knocked out. During the dental visit, it was determined that a second tooth was damaged and needed to be removed (completed during visit). Client returned to the facility. Millcreek is developing a follow up plan to address the missing teeth.
Licensing Specialist: Clayton DeBoer.
Facility visited and client interviewed. Client stated that staff immediately prevented him and peer from continuing to fight. Staff present during the incident stated she and other staff were deescalating an argument with client and other peers, when peer snuck up and punched client. Staff immediately intervened and client was taken to the nurse.
PRLU or OLTC
Accidental Injury, Notice of Incident
During recreational time in the gym, client slipped on the bleachers and obtained a laceration to her leg. Client was transported to the ER for treatment per PCP. Client returned to the facility and will follow up with her PCP. No licensing concerns noted from this report.
PRLU or OLTC
Accidental Injury, Notice of Incident
While playing basketball during recreational therapy, client went up for a rebound and came down and fell in between two other players and injured his ankle. Upon assessment, the nurse noted swelling to the right ankle. Client was transferred to the ER for treatment per PCP. Client will follow up with his PCP. No licensing concerns noted from this report.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Personnel records review conducted for 10 employees. All file licensing requirements were accounted for.
PRLU or OLTC
Medical, Notice of Incident
Client was sent to the hospital to assess a leg wound received before admission to Millcreek. The wound became inflamed, tight, and hot to the touch despite taking several rounds of antibiotics. He was later transferred to AR Children’s Hospital ER by ambulance for further assessment. No diagnosis or treatment plan has been received at this time.
No licensing issues noted from this report. Facility visited 9/12/23. Client remains at ACH at the time of visit.
PRLU or OLTC
Medical, Notice of Incident
Client was sent to the hospital for an outpatient gallbladder ultrasound. She was referred for the test by her PCP. She was released to return to the facility.
Facility visited 9/12/23. ER report stated that client has “gallbladder sludge”. No sonographic evidence of acute cholecystitis. No licensing concerns noted from this report.
Medicaid Inspection of Care
Inspection of Care Report
No deficiencies were noted during the Inpatient Psychiatric Inspection of Care (IOC) conducted on 09/05/23.
Police Report
Elopement
Officers responded to facility in reference to 3 runaway juveniles. Upon arrival, employees had one juvenile on the ground. Employees also caught the second juvenile. Officers made contact with the third juvenile and secured him in handcuffs. All juveniles were returned to their dorm.
PRLU or OLTC
Elopement, Notice of Incident, Visit Compliance Report
Three residents eloped from Magnolia Hall living unit and walked into an adjacent wooded area. Police were notified and located the residents. Estimated time away from the facility was 30 minutes.
Licensing Specialist: Clayton DeBoer.
Facility visited on 9/5/23 and client interviewed. Client stated he did not have staff/client ratio supervision of 1:1 during the incident. When asked where staff were, client stated “watching other kids.” Staff present during the incident was interviewed, who stated client was initially 1:1 with staff. Client kicked the cabin door open but staff was able to talk clients into returning inside. Later, the door was still open from being broken by client, allowing the residents to elope. Staff indicated staff/client ratio was 2:7, allowing 1:1 with client.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Buildings and grounds conducted from 11:00 AM – 12:30 PM. Deerfield observed to be clean, safe, and in good repair except for drawstrings found in a pair of sweatpants. These were immediately removed by staff. Facility sent email to have all client living areas be inventoried for strings and/or cords. MARs checked for 5 residents; All initialed and up to date.
Facility cited 911.15.f: Drawstrings in a pair of sweatpants.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact, Visit Compliance Report
Resident reported that he was in his room in Magnolia Hall with his door shut, masturbating. A peer entered the room, grabbed hold of him, and started “jacking him off.” Resident stated that this went on for about 5 minutes and then he requested that peer stop. Peer stopped and left the room. It was later determined that resident reported this to staff on 8/19/23. After review on 8/21/23, the Risk Manager notified the Child Abuse Hotline (report not accepted).
This notification is in accordance with the Corrective Action Agreement, which requires reporting of incidents that suggest inadequate supervision. According to patient safety plan, he should have one staff member assigned to him at all times until he is discharged. For safety reasons, resident was relocated to Tiger Hall, where he was separated from the alleged offender. The staff received training on the rules that require patients under 1:1 staffing to always remain within arm’s length of their caregivers.
Licensing Specialist: Clayton DeBoer.
Facility visited on 8/22/23 and interviews conducted. Peer reported that he is supervised “most of the time” and when asked how long he goes unsupervised, he stated “5 minutes”. Risk Manager clarified that client is not allowed out of arm’s length and is to be in constant line of sight of staff. Staff responsible for supervising peer stated she was supervising peer at all times and peer never went into resident’s room. This staff stated in an email that resident entered peer’s room and was told to get out and that he wasn’t supposed to be in the room (initial allegation stated the peer entered resident’s room).
The Child Abuse Hotline was called again for concerns regarding possible lack of supervision given the offenders previous true finding of maltreatment against another peer (report was screened out). No determination could be made regarding if the events occurred, or if the resident was ever left unattended. The facility will continue with the current safety plan for resident.
PRLU or OLTC
Maltreatment, Notice of Incident, Peer Altercation, Visit Compliance Report
Resident and peer were involved in a physical altercation during a card game. Staff intervened and separated the residents. After the incident, resident claimed a staff member had forcefully pushed him to be seated in a chair after the resident had tried to continue to the fight. Nursing assessment revealed redness and petechia to resident’s right inner arm. A report was made to the AR Mandated Reporter Portal and accepted for investigation. The staff member was suspended pending the investigation.
Licensing Specialist: Clayton DeBoer.
Facility visited on 8/22/23 and video reviewed. The alleged staff member can be seen grabbing resident and shoving him into a chair. After resident gets up from the chair, the staff member takes off his glasses, slapped his own head (staff’s), chest bumped resident, then shoved him back into the chair. Facility Risk Manager stated that after review of video, staff member will be terminated.
Facility cited 905.4.g and 109.1.g for staff member’s actions. Licensing founded this complaint. Crimes Against Children Division (CACD) investigation was unfounded.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Monitor visit conducted 8/16/23. Census: 158. Ratios checked today with no issues noted. Cafeteria was sanitary, safe, clean and in good repair.
PRLU or OLTC
Medical, Notice of Incident
Resident was sent to Dallas County Medical Center for an outpatient x-ray. She reported back pain to Primary Care Physician and received an order for an x-ray of her spine. X-ray report indicates a normal-appearing lumbar spine. She was released to return to the facility.
PRLU or OLTC
Medical, Notice of Incident
Resident was sent to Dallas County Medical Center for an ultrasound of his gallbladder. He reported digestive track concerns to on-site nursing. His PCP referred him for the ultrasound. The results came back as normal. He was released to return to the facility.
PRLU or OLTC
Accidental Injury, Notice of Incident
Resident was sent to Dallas County Medical Center for outpatient x-ray. Primary Care Physician referred him after reporting pain to on-site nursing after being struck in the hand by a ball during recreation time. X-ray report indicated that there were no fractures present.
PRLU or OLTC
Notice of Incident, Self-Harm
Resident was sent to Dallas County Medical Center for outpatient x-ray after an incident where she became upset and punched a metal door. On-site nursing assessed her and noted swelling to the right hand. X-ray report indicates that there are no fractures or dislocations. She was released to return to the facility.
PRLU or OLTC
Notice of Incident, Self-Harm
Resident was sent to Dallas County Medical Center for outpatient x-ray. He reported pain and swelling in his right hand after an incident where he punched a metal pole that supports a walkway awning. X-ray report indicates an acute non-displaced minimally angulated right small finger metacarpal neck fracture. He is being referred to his Primary Care Physician for further treatment.
PRLU or OLTC
Accidental Injury, Notice of Incident
Resident was sent to Dallas County Medical Center for outpatient x-ray after reporting continued pain in his jaw. The injury occurred when he unintentionally struck his jaw against another patient’s head while sliding down a water slide on 07.28.23. The x-ray report indicates that there is no fracture. He was released to return to the facility.
PRLU or OLTC
Notice of Incident, Peer Altercation, Visit Compliance Report
Resident was sitting down in a chair near the water cooler when a peer ran up and pushed him out of his chair, causing him to obtain a laceration to the left side of his head. The staff intervened and separated the patients. The nursing report indicated pain and the injury was a 2 centimeter laceration to the left side of the scalp. Resident was sent to the emergency room and received staples to his head. Resident will follow up with his Primary Care Physician.
Licensing Specialist: Clayton DeBoer.
Facility visited 8/4/23. No video was available of this incident. Resident was interviewed and stated that his peer pushed him out of a chair for no reason and that peer picks on him sometimes. Resident stated that it took “about 5 seconds” for staff to make sure he was ok. When 5 seconds was demonstrated to resident, he replied “quicker than that…right away…Mr. Bruce made sure I was ok”. Resident stated that he feels safe at Millcreek and feels comfortable speaking to staff if he feels unsafe. Supervisor of Rock Hill was consulted who stated that other living units house older, larger males who could be a threat to resident. After discussion with licensing, staff placed client on Close Observation and it was determined that he should remain at Rock Hill cottage for optimum safety.
PRLU or OLTC
Notice of Incident, Peer Altercation
Resident was involved with a peer in a recreational game of basketball. He became upset and punched a peer in the face. Initial nursing report indicated pain and swelling. After visit with Primary Care Physician on 08.01.23, he was referred to Dallas County Medical Center for outpatient x-ray. X-ray report received on 08.02.23 indicated a fracture to the 3rd metacarpal with a slight apex dorsal angulation. He will follow up with Ortho Arkansas for further treatment.
PRLU or OLTC
Notice of Incident, Peer Altercation, Visit Compliance Report
Client was sent to Dallas County Medical center ER for assessment following a physical confrontation he initiated with a peer. He was assessed for concussion and diagnosed with two fractured teeth. He was released to return to the facility with orders to follow up with a dentist. Dental appointment is scheduled for Wednesday, August 2. Client returned to a different living unit, in order to separate him from the peers involved in the confrontation.
Licensing narrative:
- Per phone call (7/31/23) with Chris Butler of Millcreek, this incident occurred at magnolia hall where there is no video footage.
- Facility visited 8/2/23 in response to 7/29/23 incident in which client was in an altercation with peer resulting in client being sent to emergency room. Nursing note reviewed. Safety plan client was moved to Tiger Hall from Magnolia Hall where incident took place and resides, upon return from ER visit. Without video of incident, licensing cannot determine for certain if there was a supervision issue or not as of 8/2/23.
- Follow up visit conducted 8/2/23 of Magnolia Hall to verify client sleeping area. Client’s bedroom is [REDACTED] of Magnolia Hall. Three beds present, with only one furnished. Room appears as though one client occupies it.
- Follow up visit conducted 8/9/23. Client was explained by [REDACTED] of Millcreek that he would need to remain in his current cottage for his safety. Without video of incident, licensing cannot determine for certain if there was a supervision issue or not as of 8/9/23.
Licensing Specialist: Clayton DeBoer.
PRLU or OLTC
Accidental Injury, Notice of Incident
Client was sent to the Dallas County Medical Center ER following a recreation injury. He sustained a laceration to the head from a collision with another patient while sliding on a water slide. The ER doctor closed the laceration with surgical staples. He was released to return to the facility. Follow up with Primary Care Physician will occur.