Resident kicked a wall during a behavior, and was taken to Dallas County Medical Center on 04/9/2024 for an x-ray on her 3rd toe on the right foot due to pain. X-ray revealed no fractures.
PRLU or OLTC
Notice of Incident, Self-Harm
PRLU or OLTC
Accidental Injury, Notice of Incident
Client was playing basketball when he fell and hurt his left great toe. Client was transported to Dallas County Medical Center for an x-ray. He was found to have a nondisplaced fracture in the distal metadiaphyseal region of proximal phalanx of the first digit.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer
After hours visit conducted at 6:00 AM. Staff/client ratio: 2:10.
Staff seen through window awake prior to arrival. Staff answered the door immediately. Nightly visual checks roster produced with appropriate time initialed. All clients were reportedly asleep. Day/living areas observed to be clean, safe, and in good repair. Grounds clean and free of safety hazards. Bathrooms and sleeping areas not observed during after hours as to not disrupt clients’ routine.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Facility visited in follow up to attempted elopement of client in January 2024. Per staff, police were notified per elopement protocol, but no arrests were made. The police department did not show up for this call. Staff reported client would converse with staff, run ahead, then converse with staff, and so on. Client eventually returned to the facility without need of physical intervention.
Background checks for 99 staff were reviewed during this visit. All checks were completed.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
On 3/19/24, client reported that a staff member hit him in the mouth and nose during an attempted elopement and physical restraint that occurred on 3/17/24. A report was made to the Arkansas Child Abuse Hotline (accepted).
Staff reported there is no video of alleged incident as it was reported to have occurred in a transit vehicle. Client attempted to elope but never made it off campus. Staff drove a facility vehicle to the edge of the road and located client, and client got in the transit vehicle where the incident allegedly occurred. Staff has been placed on administrative leave pending investigation.
Licensing Specialist: Clayton DeBoer.
3/20/24-Facility visited. Nursing note reviewed for 3/17 which does indicate that client had “abrasion to inner lip”. Facility investigation yields that alleged incident happened in transit vehicle, Shakaila Edwards driving, staff Mantrell Neal and the accused staff member riding.
The 2 staff that were also present in the transit vehicle reported that at no time did they see the accused staff member punch or hit the client. Staff Neal reported that client was restrained by the accused staff member while in the vehicle. Staff Neal did say that he saw the client spit blood, but at no time saw any staff do anything during the incident that would cause client to spit blood.
Client interviewed. Client stated that he was going to elope but stopped in the road and let staff catch him. Client stated that staff grabbed him by his hoodie with both hands and while restraining him (in transit vehicle), staff punched him “once in the nose and twice in the mouth”. When asked if any staff were present, client indicated that staff Shakaila and Mantrell were present. When asked if either of these staff saw the accused staff member hit him, client replied “I don’t know”. Client had no outwardly visible scarring or bruising on his face today but did show a healing cut on the inside of his lip.
CACD investigation was unsubstantiated. Licensing complaint unfounded.
PRLU or OLTC
Accidental Injury, Notice of Incident
Client was sent for an outpatient x-ray at Dallas County Medical Center following a visit with his PCP. He complained of continued pain resulting from a fall during a recreational basketball game. X-ray report indicates a greenstick fracture distal radius and a buckle fracture distal ulna. He has been provided a splint and will follow his PCP directives for treatment of the injury.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
Client was placed in a physical restraint following an extended period of verbal and physical aggression and property destruction. The restraint was initiated for safety after he directed his aggression toward staff members, pushing and biting them. On 3/9/24, client made the verbal statement that a staff member had choked him while initiating the physical restraint. The nurse’s notes following the restraint indicate scratches on the left side of the neck. A report was made to the Arkansas Child Abuse Hotline (accepted). The staff member was placed on administrative leave pending the investigation.
Licensing Specialist: Clayton DeBoer.
Facility reported there was no video of this incident. Witness statements reviewed.
Of note, a supervisor’s witness statement states “during the restraint at no time did I see staff [redacted] choke patient”. Witness statement continues to state that after the restraint was over, at no time did patient mention being choked. Nursing note from the day after, 3/9/24, states that client had abrasion like scratches to left side neck and base of throat and reported being choked during restraint. Client interviewed. Client stated that during the restraint, staff put his right hand around his neck, while client was lying on the ground face up. Client stated he heard another staff say “don’t choke him”. Client stated that after the restraint he did not mention being choked because of fear of retaliation from peers. Licensing attempted to contact the involved staff member by phone (no answer). Client did have a 3″ scratch to left side of neck during today’s visit.
CACD investigation was unsubstantiated. Licensing complaint unfounded.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Personnel Records Review conducted for staff. All items accounted for. Background check file reviews also conducted for 33 additional staff.
PRLU or OLTC
Accidental Injury, Notice of Incident
Client was sent to Dallas County Medical Center for an outpatient x-ray for a complaint of continued thumb pain, reported after losing his balance and catching himself. X-ray report indicates no fracture present. He was released to return to the facility without restriction.
PRLU or OLTC
Elopement, Notice of Incident
Patient eloped from the property. Patient was found within 200 yards of facility. Emergency protocol was initiated and followed. Patient returned to facility with no injuries.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Buildings and Grounds conducted from 9:45am – 11:30am. Census: 159. Pebble Creek and Pine Ridge viewed. MARs checked for 5 residents. Background checks reviewed for 99 staff.
Facility cited 911.6: Pine Ridge room 4 closet had graffiti, bathroom 4 had a missing bolt on toilet lid and baseboards were missing for entire unit (baseboards have been intentionally removed and are awaiting remodel).
PRLU or OLTC
Accidental Injury, Notice of Incident
Client injured his ankle while playing a recreational game of kickball. He complained of pain during nursing assessment. He was referred to Dallas County Medical Center for outpatient x-ray. X-ray report reveals no fracture present. He was released to return to the facility without restrictions.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact, Visit Compliance Report
During an interview with DHS Licensing regarding a separate matter, Client 2 reported Client 1 coerced him into permitting Client 1 to engage in non-consensual sexual contact. A report was made to the Arkansas Child Abuse Hotline (accepted).
Licensing Specialist: Clayton DeBoer.
This allegation was made during a facility visit on 2/12/24 (interviews were being conducted for allegations made on 2/9/24 by Client 1).
Client 1 stated that two incidents occurred, one in the dayroom in which Client 2 asked Client 1 to touch his privates, and one in his room, in which Client 2 flashed him. Client 1 stated staff were present in the cottage when these incidents occurred, and both took less than 5 minutes.
Client 2 was then interviewed, who reported that Client 1 “put his privates in me” and that Client 1 physically forced this to happen. Client 2 reported this occurred in Client 1’s room, the same evening Client 2 flashed Client 1. After interviews, staff reported the residents will be assigned different cottages and remain on close observation.
CACD investigation was unsubstantiated. Licensing complaint was unfounded.
PRLU or OLTC
Notice of Incident, Self-Harm
Client was sent to Dallas County Medical Center for an outpatient x-ray after reporting hand pain. His report was made during the examination by nursing staff after client punched a cinderblock wall. The x-ray report indicates that no acute fracture or injury was present. He was released to return to the facility without restriction.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact, Visit Compliance Report
Client 1 reported to his therapist that he was forced to inappropriately touch Client 2’s penis. A report was made to the Arkansas Child Abuse Hotline (accepted).
Licensing Specialist: Clayton DeBoer.
Facility visited 2/12/24 and residents interviewed. Client 1 stated that two incidents occurred, one in the dayroom in which Client 2 asked Client 1 to touch his privates, and one in his room, in which Client 2 flashed him. Client 1 stated staff were present in the cottage when these incidents occurred, and both took less than 5 minutes.
Client 2 was then interviewed, who reported that Client 1 “put his privates in me” and that Client 1 physically forced this to happen. Client 2 reported this occurred in Client 1’s room, the same evening Client 2 flashed Client 1. After interviews, staff reported the residents will be assigned different cottages and remain on close observation. Staff reported a new maltreatment report will be made regarding this allegation.
CACD investigation was unsubstantiated. Licensing complaint was unfounded.
PRLU or OLTC
Maltreatment, Notice of Incident, Peer Altercation, Visit Compliance Report
Client exhibited emotional distress and confrontational behavior towards other patients and staff members in her classroom setting, leading to several patients trying to initiate physical altercations with her. A review of the surveillance footage revealed that during the incident, a staff member physically assaulted client by slapping her twice on the back of the head and, while standing, yanked her legs out from under her, causing her to fall to the floor. A report to the Arkansas Child Abuse Hotline was made (accepted). The staff member involved was terminated from employment immediately. Nursing assessment revealed no injury from the incident.
Licensing Specialist: Clayton DeBoer.
Facility visited 2/12/24 and camera footage reviewed which clearly shows staff take client’s legs out from under her causing her to fall to the floor landing on her buttocks. Staff can be seen slapping the top of client’s head twice. Staff/client ratio in video 2:9. Facility cited 109.1g and 905.4g: Staff can be seen on video causing physical harm to client.
An in-service training will conducted on Therapeutic Crisis Intervention De-escalation techniques with the staff member also in the room. A campus-wide in-service will be conducted on the usage of announcing “CODE GREEN” on the walkie talkie communication, requesting additional assistance for de-escalation.
Licensing complaint is founded. 4/29/24 – CACD investigation was unfounded.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Background checks reviewed for 72 staff. No licensing concerns noted.
PRLU or OLTC
Notice of Incident, Suicide Attempt, Visit Compliance Report
Client was assisting the Activities Director with cleaning and activity preparation in her office. After returning to her living unit, client reported to the supervisor that she had taken a bottle of Ibuprofen from the Activity Director’s desk drawer and swallowed all of the pills. She stated that she regretted her actions immediately after taking them. The bottle was estimated to be ¼ to ½ full (approx. 30-50 pills). She was taken to Dallas County Medical Center ER where she received activated charcoal and fluids. She was placed on 1:1 staffing ratio upon her discharge from the hospital. A safety plan is currently being created.
Licensing Specialist: Clayton DeBoer.
Facility visited 2/8/24 and video was reviewed.
- Facility cited 908.4: Staff member left Ibuprofen in an unlocked desk drawer. Staff member involved was counseled on the importance of keeping all medications on campus locked up.
PRLU or OLTC
Accidental Injury, Notice of Incident
Client was referred to Dallas Co. Medical Center for outpatient x-ray after reporting continued hand pain to her PCP. She accidentally had a door close on her hand earlier in the week. X-ray report indicates that no fractures or joint misalignments were found.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer
Annual Review/Policies PRTF completed. All items on checklist accounted for.
Police Report
Elopement
On January 17th at approximately 8:10 A.M., Officer Murry was dispatched to Millcreek on industrial drive in Fordyce, AR for a runaway child report. Upon arrival, Officer Murry came in contact with Shavon Eason who is a PRTF LPN at Millcreek. She advised that a Juvenile ran away from the Millcreek facility at approximately 8:10 A.M. Officer Murry took the report and the juveniles information.
PRLU or OLTC
Injury Prior to Admission, Notice of Incident
Client received outpatient x-rays at Dallas County Medical Center. She was referred after reporting pain to her PCP during a wellness checkup. The x-ray report indicates that she had a previously fractured her femur and healed. The report indicated that there are two orthopedic wires in the shaft of her right femur and a possibility of arthritis from the injury. The injury occurred prior to placement with Millcreek.
PRLU or OLTC
Maltreatment, Notice of Incident, Peer Altercation, Visit Compliance Report
Client 1 reported that two patients were fighting in his living unit. He inserted himself in the physical confrontation in an effort to calm the patients down and was placed in a standing hold by 2 staff. After they released him, client attempted to punch staff members multiple times and reported that a staff member punched him in return. A second client reported that he witnessed Client 1 being punched by staff member. Client 2 confronted staff, asking why he punched his peer. It was reported that staff said, “Get the fuck out of my face. I don’t give a fuck about none of you” and then punched Client 2 in the face. Client 2 reports that he backed up but kept questioning and was punched two more times in the face. Nursing assessment: Client 1 has a swollen area behind his left ear. Client 2 was noted to have a raised area to left upper cheek area and right upper head area. No outside medical treatment was needed. The allegations were reported to the Child Abuse Hotline and accepted for investigation by DHS. Staff member was placed on administrative leave pending investigation.
Licensing Specialist: Clayton DeBoer
Facility visited. Witness statements reviewed. Clients were interviewed. Client 1 stated that he and staff had a verbal altercation before staff punched his left ear. Client 1 stated that staff “Ms. Shakaila and Deon” witnessed this. Client 2 interviewed. Client 2 stated that he was outside when staff punched him, with a close fist, “3 times” in the face. Client 2 stated that staff S Smith witnessed this. Staff S Smith interviewed during today’s visit. Staff S Smith confirmed that she witnessed staff punch Client 2 in the face 3 times. She stated she attempted to intervene to no avail.
Facility cited 109.1g and 905.4g: Staff punched 2 clients in the face. Per Chris Butler of Millcreek staff will be terminated subsequent his suspension.
Licensing founded this complaint. CACD investigation was unsubstantiated.
Police Report
Elopement
On January 04, 2024, at approximately 2:05 p.m., officer was dispatched to Millcreek in reference to a runaway patient. Upon arrival, officer made contact with staff members and was given his patient information sheet, and was informed that he was at Magnolia Hall when he ran away from the facility. Officer informed staff a report would be on file.
PRLU or OLTC
Elopement, Notice of Incident, Peer Altercation
At 1345, two patients engaged in physical confrontation while participating in outdoor recreation. Client slipped away from the group as staff member’s attention was diverted while separating the patients. Client entered a densely wooded area behind the facility and was quickly out of sight of staff members. Supervisory staff initiated the elopement search procedures immediately and notified Fordyce Police Department to assist in the search efforts. As the search progressed, the Cleveland Co. Sherriff’s office was also alerted. Client was located by Millcreek supervisory personnel approximately 200 yards away from the facility. At approximately 1915, he was willingly taken back into custody without further incident. He was searched for contraband and assessed by nursing staff before reentering his living unit. There were no injuries noted from the incident.
Licensing received email that staff/client ratio was 2:10. According to report, staff were aware of elopement and followed protocol. Client was located and taken back into custody the same day of elopement.