Disability Rights Arkansas

Millcreek Behavioral Health / Habilitation Center, Inc.

*Photos taken by DRA staff during onsite monitoring visits. Photos reflect the most recent conditions observed by DRA staff but may not reflect the current conditions at the facility. If you are associated with a facility and have updated information or photos you would like to share, please contact DRA at [email protected]

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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PRLU or OLTC

Notice of Incident, Peer Altercation, Self-Injury

  • Self-inflicted Injury, Peer Altercation
    • Client became upset after a peer punched him in the back as they returned to the living unit from lunch (staff separated them). Client punched the bedroom door with his fist. Upon assessment, nurse noted slight bruising to 5th digit on left hand. Client was sent to the ER on 01/17/23 due to continued complaints of pain, and the x-ray results indicated a fracture.
    • Licensing follow-up: Facility sent x-ray results on 01/18/23. Client will be seen by medical director for decision on treatment.

PRLU or OLTC

Children's Records Review, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Multiple children’s records reviewed.
  • Regs out of compliance –
    • 9.902.3 – Clients (3) did not have immunizations or proof of requesting immunizations

PRLU or OLTC

Notice of Incident, Suicide Attempt, Visit Compliance Report

  • Suicide Attempt
    • Client swallowed approximately 2 oz. of Pine Sol cleaner. A peer in the living unit had just completed their nightly chores, and the cleaner was accessed on a table in the day area. Poison Control was contacted and encouraged client be assessed at a medical facility. Client was sent to the ER and monitored for 6 hours; No treatment was deemed necessary. Client was placed on 1:1 supervision until 01/16/23.
    • Licensing follow-up: Licensing inquired of client status. Facility reported client has been incident free since Friday and is remorseful of his actions.
    • Facility cited for 910.1 (safety hazard was accessible to client) and 907.2 (client was not supervised for a length of time long enough to ingest safety hazard).

PRLU or OLTC

Notice of Incident, Peer Altercation

  • Peer Altercation (1)
    • After an altercation with peer, client was assessed by nurse and was given Tylenol and told to elevate his leg. On 01/12/22, he reported continued pain in his right knee. Client was sent to the ER and an x-ray indicated there was no fracture.

PRLU or OLTC

Notice of Incident, Peer Altercation

  • Peer Altercation (2)
    • Client was involved in an altercation with peer, and no complaints or injuries were noted upon nurse assessment. On 01/12/22, client reported he woke up with swelling and pain in his right hand. Client was sent to the ER and an x-ray indicated there was no fracture.

PRLU or OLTC

Notice of Incident, Self-Injury

  • Self-inflicted Injury
    • Client reported to staff that she removed the batteries from a television remote and swallowed them. Client was sent to the ER, and an x-ray showed a metallic foreign body was present in the stomach. No obstructions were noted.
    • Licensing follow-up: Facility informed Licensing on 01/13/23 that a follow-up x-ray was performed on 01/05/23 and no follow up appointment was needed.

PRLU or OLTC

Notice of Incident, Self-Injury, Visit Compliance Report

  • Self-inflicted Injury
    • Client entered staff’s office without permission and unbeknownst to staff. Client obtained scissors, brought them back to her room (violating her safety plan), and used them to self-harm. Nurse notes: Client re-opened wound to left arm and cut gashes into left hand. Wounds were cleaned and wrapped with gauze. Client was sent to the ER, and no further treatment was deemed necessary. Client was transported to acute placement without incident. Supervisory personnel performed staff in-services on patient supervision and securing doors where patient entry is prohibited.
    • Licensing follow-up: Licensing visited facility on 01/03/23. Client was on close observation and elopement precautions when incident occurred. Video was reviewed: Client was seen leaving group, walking down the hall, and observed staff’s office to be open. Client enters then exits the office and enters her room. Client was observed by staff 11 minutes later without incident; 29 minutes after this, 2 peers looked into client’s room and ran to get staff. At this point, staff notice client has been injured. Facility was cited 907.2 and 910.1. Staff involved were retrained on securing offices and supervision.

PRLU or OLTC

Notice of Incident, Self-Injury

  • Self-inflicted Injury
    • Client punched a wall after she observed a peer that she likes speaking with another peer. Nurse noted moderate edema over 4th metacarpal; Icepack and Advil provided. Client was sent to the ER for an x-ray and no fractures were noted.
    • Licensing follow-up: The incident was reviewed and contained no licensing violations at this time. The client is being treated with over-the-counter medications for pain/swelling.

Police Report

Welfare Check

Caller stated she received a call from the facility stating her daughter was jumped by another kid. Caller stated she had been trying to talk to her daughter, and every time she calls, the facility hangs up on her. Officer spoke with a staff member and was advised they would call the guardian back and talk to her about her daughter.

PRLU or OLTC

Notice of Incident, Self-Injury

  • Self-inflicted Injury
    • When performing patient checks, staff discovered client after an incident of self-injurious behavior. Client was noted to have a 3-inch laceration to her left forearm in addition to superficial scratches. Nurse treated wounds and client was taken to the ER, where she received 4 sutures to her forearm. The entire cottage was searched to ensure children’s personal items cannot be used to inflict self-injury.
    • Licensing follow-up: The incident occurred in the patient’s bedroom, and she used a broken glass bottle of nail polish. Video is available for review. Client is a new admit and was on Close Observation and elopement precaution for the first 30 days. After incident, client was placed on unit restriction for 72 hours. Facility visited on 12/29/22 and was cited 910.1 (grounds shall be kept clean and free of safety hazards). 

PRLU or OLTC

Accidental Injury, Notice of Incident

  • Accidental Injury
    • Client slipped and fell while playing basketball, attempting to catch herself with her arm. Nurse assessed, no swelling noted, and icepack was provided. On 12/18/22, client reported continued pain and nurse noted mild edema to left wrist. Client was referred to ER and diagnosed. Client referred for a follow-up appointment at orthopedic clinic.

PRLU or OLTC

Notice of Incident, Peer Altercation, Visit Compliance Report

  • Peer Altercation
    • Client was in a physical altercation with peer, during which she was bit on the bottom of her 4th toe on her right foot. She was referred to the ER due to the deep laceration and received 4 stitches.
    • Licensing follow-up: Licensing visited facility on 12/16/22 to review camera footage. Client is seen arguing with a peer and staff present stands in between them. Peer eventually attacks client and a fight ensues for about 20 seconds, with staff member attempting to break it up before the additional staff arrive. No further physical confrontation is seen in the video.

PRLU or OLTC

Medical, Notice of Incident

  • Medical
    • Client had a temp of 104 and was transported to the ER. Client was diagnosed and returned to the facility.

PRLU or OLTC

Accidental Injury, Notice of Incident

  • Accidental Injury
    • Client and peer collided while playing dodgeball, bumping their heads together. Client sat in the corner to recover from the collision, and when questioned by staff if he was okay, client did not respond verbally. Client was sent to the ER. CT scan was clear, and client returned to the facility with orders for continued neuro checks and to take Tylenol as needed.

PRLU or OLTC

Medical, Notice of Incident

  • Medical
    • Client came into contact with food containing peanuts and reported feeling a tingling on her tongue to the nurse. EPI pen was administered immediately and client was taken to the ER. No further treatment was necessary, and she returned to facility.
    • Licensing follow-up: Licensing inquired of a safety plan for client on 12/12/22. Facility responded, stating this was a known allergy by the patient and client has the EPI pen for that purpose. Facility stated client received the candy from a staff member, and that the client took a bite and spit it out, realizing that it contained peanuts. Safety Plan: Ensure allergy posting are present on units and conducting an in-service with staff on client’s allergy. Facility visited on 12/16/22. It was reported that staff gave client candy with peanuts, unknowing of client’s allergy; Facility was cited 903.2.

PRLU or OLTC

Notice of Incident, Sexual Contact

  • Peer Sexual Contact
    • Client 1 reported to his therapist that a peer asked him to perform oral sex on him, and that he did it because peer threatened him. This reportedly happened on 2 occasions. Client 2 reported he performed oral sex on peer because he felt he would be harmed if he didn’t. Peer stated that both Client 1 & 2 did perform oral sex on him but stated that each were willing participants. Child Abuse Hotline was called and accepted. Patients were separated to different living units and placed on Close Observation. Internal investigation is ongoing.
    • Licensing follow-up: Licensing visited facility on 12/06/22 and observed interviews with residents. Client 1 stated that last Friday, peer offered him a snack if he came into his room, and once client entered, peer pulled his pants down and sexually assaulted client with his hands and mouth. Client 1 stated this lasted 30 seconds, and that 3 staff were in the hallway helping with showers. Client 1 also stated that peer had grabbed his “front” “about 2 weeks ago.” Client 2 was interviewed, who stated that peer had offered to let him borrow headphones, and once in peer’s room, peer stated “suck my dick or I’ll beat your ass.” Client 2 stated he was afraid, so he did and it lasted for about 5 minutes. Witness statements and interviews did not indicate that staff were neglectful in supervising clients for more than a 5-minute time period. CACD investigation was unsubstantiated. Licensing complaint unfounded. 

Police Report

Battery Second Degree, Radio Log

Officer spoke with a guardian of juvenile at facility on 12/02/22; Guardian stated juvenile was assaulted by a peer and is having emergency surgery and stated the incident occurred on 11/26/22. Officer spoke with staff at facility on 12/06/22, who stated the peer hit juvenile 3 times in his eye, resulting in 3 fractures. On 12/12/22, Juvenile Officer advised she would find out if they can proceed with charges.

PRLU or OLTC

Monitor Visit, Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Buildings & Grounds conducted from 9:30am – 11am. Census: 159. Penguin area, Flamingo area, and cafeteria observed. MARs checked for 5 residents.
  • TA –
    • 9.911.6 – Room in Penguin area had graffiti on the wall.

PRLU or OLTC

Accidental Injury, Notice of Incident, Visit Compliance Report

  • Accidental Injury
    • Client reported thumb pain to the nurse caused from rearranging her bedroom. Client stated a peer had pushed her bedframe against the wall causing her hand to become pinned. Client was taken to the ER on 12/01/22 and diagnosed. Treatment included directions to splint the injured thumb.
    • Licensing follow-up: Licensing visited facility on 12/05/22 and interviewed residents. Peer reported her and client were changing rooms and while helping client move her bed, client’s thumb got smashed behind a door. Clients confirmed staff were watching them. No licensing concerns regarding this incident. 

PRLU or OLTC

Accidental Injury, Notice of Incident

  • Accidental Injury
    • Client reported pain and swelling to his right hand from falling earlier in the day. Client was sent to the ER. No fractures.

PRLU or OLTC

Notice of Incident, Self-Injury

  • Self-inflicted Injury
    • Client intentionally kicked a wall with his right foot. On 11/29/22 client was referred to the ER after continued complaints of pain and swelling.
    • Licensing follow-up: Email from facility on 11/30/22 stated no fractures were present.

PRLU or OLTC

Notice of Incident, Peer Altercation, Visit Compliance Report

  • Peer Altercation
    • At 0922, A group of peers took and refused to return a staff member’s soda bottle. After it was dropped, client picked it up and returned it to staff. Peer then approached client and punched him 3 times in the right eye. Nurse assessment revealed swelling and bruising to client’s eye, client denied vision difficulties. At 1700, client’s eye was swollen shut and client had vomited. Client was sent to the ER and was diagnosed with a fracture to the right occipital lobe. Client was referred to the Children’s Hospital, where he was released to follow-up with an ENT specialist.
    • Licensing follow-up: Licensing visited facility on 11/29/22 and viewed camera footage. Two staff members present did not attempt to stop peer from punching client nor attempted to protect client afterwards. Facility was cited 907.2. 

PRLU or OLTC

Notice of Incident, Sexual Contact

  • Peer Sexual Contact
    • During a therapy session, client reported that a peer entered the laundry room, turned off the light, and stated he was going to rape client. Client stated he yelled, and that peer was “feeling” on him. Staff came to the door and both residents exited. Peer admitted to turning off the light and locking the door but denied making any comment about rape or touching client. Peer stated he was “just playing.” Both residents have been separated to different living units and peer has been moved to a private room. Clinical team review and treatment planning changes are in progress. Child Abuse Hotline was called and screened out. 
    • Licensing follow-up: Facility visited on 11/29/22 and both residents were interviewed. Peer admitted to making statement that he would rape client, but stated he was “just playing”. Client stated peer was “just playing” as well, and that he feels safe at the facility and staff are available most of the time.

Police Report

Third Degree Escape

Officer was dispatched at approx. 1545 hours for report of an escapee. Upon arrival, staff stated a juvenile had escaped at approx 1515 hours. Officer searched the area. Staff later advised officer that juvenile was back in the custody of staff at approx. 2035 hours.

PRLU or OLTC

Injury Follow-up, Notice of Incident

  • Injury Follow-up
    • Client attended a follow-up appointment with orthopedic clinic to assess the healing process of a fracture sustained on 10/08/22. X-ray revealed the fracture was closed and client was released to wean off crutches as can be tolerated. A follow-up appointment was scheduled for 4 weeks to assess the injury again.
    • Licensing follow-up: Received x-ray notification from facility. Continue to monitor.