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
Visit Compliance Report
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.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
Patient reported a fading bruise. When questioned on the origin of the bruise, he stated, “[REDACTED] did it.” Client explained that last week (unable to give an exact date/Time), he and a peer engaged in a physical confrontation. [REDACTED] picked up a chair to throw at the peer. Staff member got the chair away from and stepped in between the two patients, grabbing them on the upper part of the arm. Client continued to explain that the incident was over once [REDACTED] separated them. Nursing report indicates that [REDACTED] has a brownish-green bruising on his left bicep. The allegation was accepted for investigation by referral id: [REDACTED]. Staff member was immediately placed on administrative leave, pending the results of the investigation. Licensing narrative:
- 7/27/2023- Program Coordinator determined that no investigator with [REDACTED] has been assigned to this case yet. Licensing is unable to obtain permission to contact the agency at this time.
- 7/27/23-Phone call made to [REDACTED] of Millcreek who stated there was no video of the incident.
- 7/27/23-Phone call made to investigator [REDACTED] who gave permission for licensing to interview alleged victim. Investigator scheduled a visit with licensing at Millcreek for 9:00 AM 7/28/23.
- Facility visited 7/28/23 in response to complaint that staff grabbed clients arm causing a bruise. Licensing attended interview with investigator and alleged victim. Witness statements from staff and client reviewed. Neither indicated unprofessional behavior on the part of staff. Licensing is not prepared to make a finding at this time.
- 8/31/23-Maltreatment report closed as unsubstantiated. 8/31/23: maltreatment report for case#[REDACTED] closed as unsubstantiated. Staff suspended 7/26/23 immediately following incident.
- Received email 9/1/23 from [REDACTED] of millcreek that staff is still employed at Millcreek and received “Restraint training (Breaking up fights with minimal force)” 8/10/23 and was returned to work 8/10/23. This was not approved by licensing. Chris Butler of Millcreek reminded of licensing regulation 110.10 – any interim action measures shall be approved by the licensing unit.
Regulations needing technical assistance: 905.9 – client reported that staff bruised his arm during a restraint. Licensing Specialist: Clayton DeBoer.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
Resident became non-compliant when prompted to get out of bed, and later reported on a phone call to her parents that she was dragged out of her bed and beaten up by staff member. Resident reported she was dragged by her wrists and ankles, and her hair pulled to the point that strands broke off. A pin-point red area was noted to resident’s inner ankle and her knee. This was reported to the hotline and accepted for investigation. Staff member was placed on administrative leave pending the investigation.
Licensing Specialist: Clayton DeBoer.
Facility reported there is video for the day in question (7/23/23), but the resident has since stated the incident happened a week, a couple weeks, or maybe a month ago.
Facility visited 7/26/23 and interviews conducted. Resident reported that about 2 weeks ago, staff member pulled her hair and then apologized. Resident reported that about 1 week after this, staff member grabbed her arm and leg and dragged her off her bed, stating 2 staff members witnessed this. Licensing reviewed a witness statement related to the first incident, in which a peer does state that staff member pulled resident’s hair when attempting to pull her jacket hood.
Two staff were interviewed who stated they have never witnessed the alleged staff member get physical with any resident.
Licensing unfounded complaint. Crimes Against Children Division (CACD) investigation was unsubstantiated.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
Resident reported that on 7/14/23, a staff member engaged in a verbal confrontation with him, calling him a “bitch” and his mother a “hoe”. Resident also reported that after this, another staff member grabbed him by his shirt and swung him between 2 beds. This was reported to the hotline and accepted for investigation. Both staff members were placed on administrative leave pending the investigation.
Licensing Specialist: Clayton DeBoer.
Facility visited on 7/18/23 and video reviewed. Facility reported there is video of client interacting with staff, but no video footage of where the incidents took place (laundry room and bedroom). Licensing observed what appeared to be a verbal confrontation occur between resident and staff member over a basket of laundry. Four peers were interviewed and denied female staff cursing or being physical with them, but stated the following regarding the male staff member:
- Staff “throws us across the room”.
- Staff “flicked me in the mouth…twisted my arm…pushed me down on the court”.
- He had seen staff “grab a kid by his arm…nothing bad”.
- Staff “twists arms” and had done this to him. Staff does this until it hurts and resident is unable to get away from the hold.
Licensing made a separate hotline report regarding the allegations made by 3 residents interviewed (accepted for investigation). After the interviews were conducted, the facility reported the male staff member’s suspension will be moved to termination.
Licensing unfounded complaint. Both Crimes Against Children Division (CACD) investigations were unsubstantiated. Facility reported the male staff member’s last day of employment was 7/21/23, and the female staff member is no longer employed and her last day was 7/14/23.
PRLU or OLTC
Notice of Incident, Peer Altercation
Client was sent to the Dallas County Medical Center for assessment following a physical confrontation with a peer. She was punched in the face, receiving a small laceration above the left eye. The laceration was treated with Dermabond and she was released to return to the facility.
Licensing narrative: Facility visited 7/18/23 and video reviewed of the altercation involving [REDACTED] from 7/13/23 which occurred in penguin hall. Hall video reviewed which shows one staff standing and one sitting. One client aggressively enters a bedroom. Within seconds staff present respond by following. The client who appears to be the aggressor leaves the bedroom. The client who seems to have been attacked by the aggressor exits her room aggressively as to retaliate. At this point, 7 additional staff are present and briefly restrain this client. All staff viewed in video seem to respond to this incident as fast as possible.
PRLU or OLTC
Visit Compliance Report
After hours buildings & grounds conducted for Deerfield from 5:45 PM – 6:45 PM. Staff/Client ratio 2:12. Living area and sleeping area clean, safe and in good repair except bedroom 2 had 4″X4″ hole in laminate tile. Maintenance order was put in to have that piece of laminate tile replaced. All other floor areas in Deerfield in good condition. Bathrooms clean and sanitary with functioning sinks and toilets. Showers had hot water. Grounds outside Deerfield were clean and free of safety hazards. MAR checked for:[REDACTED]. All initialed and up to date.
Regulations needing technical assistance: 911.6 – bedroom 2 of Deerfield had a 4″X4″ hole in laminate tile. Maintenance order was put in to have that piece of laminate tile replaced. Licensing Specialist: Clayton DeBoer.
PRLU or OLTC
Notice of Incident, Peer Altercation
Client was sent to Dallas County Medical Center for outpatient x-rays after reporting pain in his hand. The injury was a result of a physical confrontation on 7/7/23. X-ray report has not been received at the time of this report. He was released to return to the facility.
Licensing narrative: Received email from facility 7/13/23 that client’s [REDACTED] is [REDACTED] and there is no video footage of the confrontation. Also, x-ray results indicate no fracture was found.
PRLU or OLTC
Notice of Incident, Self-Harm
Client was referred to Dallas County Medical Center for outpatient x-ray after reporting pain in his hand following an incident in which he punched a wall. No fracture was found, and he was released to return to the facility without restriction. Licensing narrative: no licensing concerns noted from this incident.
PRLU or OLTC
Notice of Incident, Self-Harm
Client was referred to Dallas County Medical Center for outpatient x-ray after reporting pain in his hand following an incident in which he punched a wall. No fracture was found, and he was released to return to the facility without restriction. Licensing narrative: no licensing concerns noted from this incident.
PRLU or OLTC
Accidental Injury, Notice of Incident
Client was referred to Dallas County Medical Center for outpatient x-ray after reporting pain in his hand following a recreational game of basketball. No fracture was found, and he was released to return to the facility without restriction. Licensing narrative: no licensing concerns noted from this incident.
PRLU or OLTC
Accidental Injury, Notice of Incident
Client was sent to Dallas County Medical Center for outpatient x-ray. She reported pain in her wrist after slipping in her bedroom while changing clothes and trying to catch herself when falling. X-ray report indicates that no fracture was found. She was returned to the facility without restriction. Licensing narrative: no licensing concerns noted in complaint. Client remains at the facility.
PRLU or OLTC
Accidental Injury, Notice of Incident
Client reported foot pain after playing a game of kickball. After seeing the medical director, she was referred to Dallas County Medical Center for outpatient x-ray. No fracture was found. She was released to return to the facility without restriction. No licensing concerns noted from this incident.
PRLU or OLTC
Visit Compliance Report
Buildings & grounds conducted from 11:00 AM – 12:00 AM. Zebra and Flamingo halls inspected.
Zebra staff client ratio – 3:16. Flamingo staff/client ratio – 2:5 (some clients on field trip). All buildings and grounds clean, safe and in good repair other than previously addressed holes/tears in laminate tiles, which facility is replacing unit- wide and two showers in Zebra hall. Two showers in Zebra hall had, per staff, not been working for about two days and a maintenance order had been placed for this. Sleeping areas furnished and in good repair. Bathrooms clean and sanitary. Day room’s clean, furnished and in good repair. Clients present in day room areas were engaged in activities. MAR checked for: [REDACTED]. Regulations needing technical assistance: 911.6 – all 3 showers in zebra hall will need to be fully functional. Maintenance order has been placed before today’s visit. Licensing Specialist: Clayton DeBoer.
PRLU or OLTC
Notice of Incident, Self-Harm
Client was referred to Dallas County Medical Center (DCMC) for outpatient x-ray of his right hand. His injury resulted from an incident where he punched a wall on 06/25/23 after a phone call with his father. X-ray report received on 06/28/23 indicates a fracture but is inconclusive on whether this injury is from the current incident or a previously healed fracture. A follow up appointment with Primary Care Physician is scheduled for 06/29/23.
PRLU or OLTC
Notice of Incident, Peer Sexual Contact, Visit Compliance Report
Alleged victim is [REDACTED]. Alleged offender is a former roommate at Millcreek. Alleged victim communicated that while he was at Millcreek in 2022, his roommate raped him. He reports that he was in the Pebble Ranch cabin, and it occurred after bed checks. It was prior to December of 2022. Alleged victim stated that he told his therapist at Millcreek, but she did nothing about it and “blamed him”. He stated that his roommate climbed into his bed after bed checks, pulled down his pants, and raped him. He stated that his roommate was also older and bigger than him and was “mixed”.
Licensing narrative:
- Licensing was given approval by investigator via phone 6/26/23 to contact facility.
- Phone call made to facility 6/26/23 to confirm that was a Millcreek psychiatric residential treatment facility (PRTF) client and that his therapist was [REDACTED].
- Visit scheduled for 6/27/23.
- Facility visited 6/27/23 in response to complaint. All therapy notes reviewed for client nothing in therapy notes is indicative of subject matter in complaint. Licensing is not prepared to make a finding at this time. [REDACTED] was client’s last assigned therapist. Therapy notes reviewed included notes from staff/therapists/therapist interns [REDACTED] and [REDACTED].
- 8/3/2023 – Maltreatment investigation is still open and pending at this time.
- 9/5/23 – Case#[REDACTED]. Maltreatment complaint unsubstantiated.
Licensing Specialist: Clayton DeBoer.