Licensing Specialist: Clayton DeBoer
Personnel Records Review conducted. All items required per minimum licensing standards observed.
PRLU or OLTC
Visit Compliance Report
PRLU or OLTC
Notice of Incident, Self-Harm
Resident was sent for an outpatient x-ray at Dallas County Medical Center. She was assessed by on-site nursing after an episode of self-injury where she kicked a door. X-ray report indicates there were no fractures present. She was released to return to the facility.
PRLU or OLTC
Notice of Incident, Self-Harm
Resident was sent for an outpatient x-ray at Dallas County Medical Center. She was assessed by on-site nursing after an episode of self-injury where she punched a wall. X-ray report indicates a minimally displaced fracture of the fifth digit. Dallas County ER provided a splint, and she was released to return to the facility. PCP will oversee her recovery from the injury.
PRLU or OLTC
Accidental Injury, Notice of Incident
Resident opened a fence gate that led to the outdoor walking trail and received an injury from metal found on the gate. Following onsite nursing assessment, she was referred to Dallas County Medical Center ER for assessment and treatment. Surgical stitches were used to close the laceration on her 3rd digit, and Dermabond was used to close a minor laceration on her 5th digit. She was released to return to the facility. Her PCP will oversee any further medical care needs. The fence gate has been secured to prevent any future injuries similar to this incident.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Facility visited from 10:00AM-11:00AM. Video reviewed of the late night/early morning hours of October 25th, 27th and 29th for Tiger Hall, Flamingo Hall and Zebra Hall. All staff/client ratios viewed within licensing standard of staff/client ratio for sleeping hours 1:8.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Buildings & Grounds conducted from 9:30AM-10:30AM. Census: 160. Outdoor play area staff/client ratio: 2:12. Rock Hill observed to be clean, safe and in good repair except for previously identified worn down spots in laminate tile. Millcreek is having tile replaced throughout facility, Rock Hill in line for the future. MAR checked for 5 residents. No licensing concerns noted during visit.
PRLU or OLTC
Notice of Incident, Self-Harm
On the evening of 10.11.23, client became upset and punched a wall. The swelling was noted initially but could also be a result of a previous injury sustained prior to admission that presented continued tissue swelling without the presence of a fracture. She was seen by her PCP on 10.13.23 and referred for x-ray at Dallas County Medical Center. X-ray report reflects moderate soft tissue swelling about the ulnar wrist without acute fracture or dislocation.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact, Visit Compliance Report
Client reported that on 10/05/23, a peer made him “suck him off.” Client stated he “tried to say no, but the kid said he would give me clothes, so I said OK, to make him shut up.” Clothes were exchanged between the two peers. Peer was moved to a different living unit and placed on Close Observation to prevent future occurrences. Child Abuse Hotline was called but not accepted due to a duplicate entry. On 10/11/23, Millcreek received notification that a report was made by an outside entity and accepted for investigation by CACD. The report alleged that client woke from sleep to find a penis in his mouth. He was forced to continue to perform oral sex until the peer ejaculated in his mouth. The report also alleged concerns with patient supervision by direct care staff at Millcreek.
Licensing Specialist: Clayton DeBoer.
Facility visited 10/12/23. Peer was interviewed and denied this incident ever took place. Peer stated client is saying this because he is afraid peer is going to beat him up over some necklaces and also to be moved closer to his girlfriend who resides at Millcreek. Peer repeated that this incident never took place adding that he has a girlfriend at home and is not homosexual. Peer stated that he has never seen all 3 staff (17 clients at Pine Ridge) leave Pine Ridge at any given time. He stated that staff do take breaks but other staff relieve them. Client was interviewed and stated that staff were absent from his living area when this incident occurred. Client stated “[staff 1] said he was going to the smoke shack”, “[staff 2] went out back to vape” and “[staff 3] went to get Taco Bell…I know because I saw the big Taco Bell sack”. Client stated the incident took around 3-4 minutes.
CACD investigation was unsubstantiated. This complaint is unfounded by Licensing.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Buildings & Grounds conducted for Penguin Hall from 10:30AM-11:30AM. Census: 12. Penguin Hall recently painted, new floors installed. Day area, bedrooms, hallway, and bathrooms viewed. MARs checked for 5 residents. No licensing concerns noted during visit.
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. On-site nursing indicated bruising and swelling to the facial area. The CT scan indicates no fractures were present. Upon his return, he was reassigned to an alternate living unit to provide safety and reduce the chance of future incidents.
Licensing Specialist: Clayton DeBoer.
Staff reported there is no camera footage of incident. Facility visited 10/3/23. Client was interviewed and stated that there were two staff assigned to Magnolia Hall at the time of the incident but that one staff member had “gone to get trays”. Chris Butler of Millcreek indicated that this would typically take 8-10 minutes. Client stated that the other staff member present did not intervene after he was “jumped” by peers. Client presented today with swollen and bruised face. Staff, present and absent from Magnolia, if even for a brief period, failed to ensure the safety and well-being of client during this incident. Facility will conduct in-service training for staff involved in this incident that staff/client ratio will be ensured at all times.
Facility cited 907. 2: Staff did not ensure the safety and well-being of client during this incident resulting in the swelling/bruising of face.
Facility cited 907. 3: One staff left Magnolia Hall resulting in staff/client ratio 1:8.
PRLU or OLTC
Notice of Incident, Self-Harm
Client was sent to the hospital for outpatient x-ray after reassessment from an injury the previous day. Client had punched a wall when he was instructed by staff members to give up a basketball. X-ray report indicates that no fractures are present.
PRLU or OLTC
Visit Compliance Report
Licensing Specialist: Clayton DeBoer.
Facility visited and random video reviewed of cottages during evening hours. No licensing concerns noted.
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.