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
Elopement, Notice of Incident
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.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer
Visit conducted 1/3/24. This is to confirm that applicant is not employed by Millcreek of Arkansas.
Police Report
Arrest, Battery, Elopement
At approximately 4:45, officers were dispatched to Millcreek of Arkansas for a runaway juvenile. Staff advised the juvenile jumped the back fence and ran into the woods. Officers searched the area and then left the scene to another call.
At approximately 5:45 PM officers were dispatched back to Millcreek because someone had reported they could hear the juvenile in the woods yelling. After locating the juvenile, Ofc. Murry called over the radio that the juvenile was trying to take control of Ofc. Murry’s taser. Ofc. Byrne and Sgt. Hogan ran to Ofc. Murry and found him and a few members of Millcreek staff had the juvenile face down on the ground trying to gain control of his hands. Ofc. Byrne and Sgt. Hogan assisted him in gaining control of the juvenile who refused to give up his hands and continued to pull away and try to fight.
Ofc. Murray and Sgt. Hogan gained control of the juvenile’s hands and placed him into handcuffs, then escorted him to a patrol vehicle. Juvenile refused to get into the vehicle. Once in the vehicle the juvenile kept trying to get out of the vehicle. Ofc. Hogan tried to use the brachial plexus nerve stun with an open hand to gain control of him and missed the target area and caught juvenile in the left side of his face due to him thrashing around while Sgt. Hogan tried to get his seat belt buckled. Still unable to safely buckle him into the vehicle, Sgt. Hogan tried to hit his brachial plexus nerve area two more times and missed. After being held at taser point by Ofc. Murry, Sgt. Hogan got him buckled in the vehicle.
Ofc. Murry then began to transport juvenile to the Dallas County Jail. Juvenile began to kick Ofc. Murry’s windows and doors. At the jail Sgt. Hogan put leg shackles on the juvenile. The jail staff informed us that they could not hold him due to him being a juvenile. Supervisor Lt. Swiger informed officers to take juvenile back to Millcreek and have them keep possession of him. Juvenile was transported back to Millcreek, during which he made several threats to kill officers. Officers removed the handcuffs and leg shackles once Millcreek staff took control of the juvenile.
PRLU or OLTC
Elopement, Notice of Incident
Client became upset and eloped from his living unit, jumped a fence and entered a wooded area. Elopement protocol was initiated, and search efforts began. Fordyce Police Department was called. Client was located on facility grounds and became combative with police and staff. Client alleged to have been injured by police during altercation. Report does not indicate a staff supervision issue. Elopement protocol was followed. Complaint was alleged against Fordyce Police Department.
12/19/23-Phone call made to Chris Butler of Millcreek around 2:30PM. Client had a Dr.’s appt. at 1:00PM. Results are not available yet. Results will be emailed to licensing upon receipt. Client remains at facility. Client was out of supervision of staff for a period of time before being apprehended on facility grounds. Staff were immediately aware of elopement and followed protocol.
PRLU or OLTC
Accidental Injury, Notice of Incident
Resident was referred to the Dallas County Medical Center for an outpatient x-ray. Resident reported foot pain resulting from a recreational injury that she sustained while playing volleyball. The nursing staff present on-site noted swelling in her right ankle. Upon further examination, the x-ray report indicated that there was no fracture present in her foot.
PRLU or OLTC
Injury Prior to Admission, Notice of Incident
Client was referred to Dallas County Medical Center for outpatient x-ray. He presented with complaints of back pain related to an injury sustained prior to admission to Millcreek. X-ray report indicates that no fracture is present.
PRLU or OLTC
Accidental Injury, Notice of Incident
Resident was referred by her PCP to Dallas County Medical Center for outpatient x-ray. The x-ray report indicated that no fractures were present, and she was released from the facility without any restrictions.
She had reported experiencing pain in her thumb, following an incident where staff members had to remove rocks from her hand during a de-escalation process while attempting to prevent her from leaving the facility grounds. Resident had become upset and left the school building, and while outside, she picked up rocks and gestured as if she would throw them at the staff members. To prevent any harm, the staff members secured her hand and removed the rocks from it.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer
Buildings and Grounds conducted from 9:30 AM – 10:30 AM. Census: 156
Eagle Hall and Tiger Hall observed to be clean, safe and in good repair. Both Eagle and Tiger Hall have new flooring installed in hallways and have recently been repainted except for door frames, which are scheduled to be painted. Bathrooms clean and sanitary with functioning sinks, showers and toilets. Fire drill log checked today, most recent being completed in November. Outdoor area clean and free of safety hazards.
MAR checked. All but PM meds initialed and up to date. PM meds were not marked for 12/5/23. Facility cited 908.8. DON will consult with nursing staff on the importance of timely medication administration documentation.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer
Annual Reviews/Policies PRTF completed. All items on checklist accounted for.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
Resident was in the laundry room and [staff member] told her to get out. When she did not listen, staff went to physically remove her and client hit staff. Staff then hit client in the head with a closed fist multiple times. The reporter stated that there was no bruising or blood anywhere. Staff was placed on administrative leave pending investigation.
Licensing Specialist: Clayton DeBoer
Client interviewed in response to complaint that A/O physically assaulted client. Client stated that she was aware of an incident in which “all but 2 staff showed up” in which her and staff were “playing…but we never touched each other”. Client stated that staff has never hit her or been mean to her. Client stated that staff at Millcreek were nice and that she felt comfortable talking to staff at Millcreek if she felt she needed to. Video reviewed of Flamingo Hall from 11/15/23 from 6:30AM-12:00PM. No altercation outside or around the laundry area is seen in this review of video.
CACD investigation and Licensing complaint unfounded.