- Medical 1
- Client was sent to the ER after complaining of sore throat, nausea, and consistent cough. Diagnosis: Encounter for screening, unspecified.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Medical, Notice of Incident
PRLU or OLTC
Medical, Notice of Incident
- Medical 2
- Client was sent to the ER after complaining of feeling cold, loss of appetite, sore throat, nausea, and consistent cough. Diagnosis: Cough.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Medical, Notice of Incident
- Medical
- Client was sent to the ER after complaining of abdominal pain and nausea. Diagnosis: Constipation.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Accidental Injury, Notice of Incident
- Accidental Injury 1
- Client complained of pain and swelling to his ankle from playing kickball outside. Client was sent to the ER; No acute osseous abnormality of the R ankle.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Accidental Injury, Notice of Incident
- Accidental Injury 2
- Client complained of pain and swelling to his hand from playing basketball. Client was sent to the ER; No acute osseous abnormality of the R hand.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Notice of Incident, Peer Altercation, Visit Compliance Report
- Peer Altercation
- Client reported to nurse that he was horseplaying with a peer and obtained a laceration to his eyebrow. Client was sent to the ER and diagnosed with a laceration to R eyelid and periocular area. Both residents were placed on assault precautions and peer restrictions.
- Licensing follow-up: Licensing interviewed client on 01/20/23. Client stated he injured his eyebrow on the television while horseplaying in the dayroom, and stated staff redirected him to stop but he didn’t until he injured himself.
PRLU or OLTC
Notice of Incident, Sexual Contact, Visit Compliance Report
- Peer Sexual Contact
- During phone call, client told his mother that his roommate was hitting him with a stuffed animal. Client stated he would do anything to make it stop, and the peer allegedly pulled down his pants and forced client to perform oral sex on him in their room. No injuries noted. The residents have been assigned to single room placements, peer restricted, assessed by their clinical therapist, and both were placed on a sexual safety plan. Child Abuse Hotline was called and accepted.
- Licensing follow-up: Licensing received witness statements and inquired about the sexual safety plans; No camera footage was available due to the incident taking place in a bedroom. Licensing was informed by CACD investigator that case was closed. Licensing complaint is unfounded.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury
- Client complained of pain with mild swelling to his finger after punching his mattress. Client stated he was using his coping skills. Client was sent to the ER for an x-ray, which showed no fracture or dislocation. Client was placed on self-harm precautions.
- Licensing follow-up: Licensing was informed the client was placed on self-harm precautions due to taking his mattress off the bed, placing the mattress on the wall to punch, and causing a self-inflicted injury. No licensing concerns noted.
PRLU or OLTC
Notice of Incident, Self-Injury, Visit Compliance Report
- Self-inflicted Injury
- Client reported he found 2 staples in the quiet room and swallowed them. Client was sent to the ER for an x-ray, which showed no foreign bodies. Client was placed on line of sight.
- Licensing follow-up: Licensing was informed the client did not swallow the staples based on the x-ray. Staff reported the teachers have been made aware for staples to be kept out of view of residents and that residents are not allowed behind or around teachers’ desks. Staff reported daily walk-throughs of facility are conducted, and black tape has been placed on the floor to mark how close residents are allowed to teacher’s desk.
PRLU or OLTC
Notice of Incident, Peer Altercation
- Peer Altercation
- Client complained of wrist pain after altercation with peer. Client was sent to the ER and diagnosed. Resident was placed on assault precautions and peer restrictions.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Notice of Incident, Sexual Contact, Visit Compliance Report
- Peer Sexual Contact
- Client reported that around bedtime, he snuck into his peer’s room, got behind the door, and they began kissing. Client stated his peer grabbed the back of his head, pulled it in front of his private area and told him to “suck it”. Client confirmed he performed oral sex on his peer. An internal investigation was conducted, camera footage reviewed, interviews and witness statements collected. Client has been in a single room assignment since admission due to his history. The residents have been placed on peer restriction, sexual safety plans, and line of sight, and seen by their clinical therapist. Child Abuse Hotline was called and screened out.
- Licensing follow-up: Licensing reviewed video on 01/05/23. Camera footage showed 2 staff members at each end of the hallway; Client was observed standing in the doorway of a bedroom, and after entering, a peer was observed standing in the door. Client then quickly left the bedroom and walked down the hall. After reviewing camera footage and witness statements, no licensing concerns were observed regarding this incident.
PRLU or OLTC
Notice of Incident, Peer Altercation, Visit Compliance Report
- Peer Altercation
- After altercation with peer, client complained of pain to his cheek area with swelling and bruising. Client’s temple area presented with bruising and abrasions. Client was sent to the ER and diagnosed with contusion of head. Resident was placed on assault precautions and peer restrictions.
- Licensing follow-up: Licensing reviewed camera footage and noted staff were in ratio 2:12. Due to the camera angle, licensing was unable to view the altercation, but did observe both staff present who separated residents. No licensing concerns observed.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury
- Client complained of swelling and pain to hand after punching the wall in his bedroom. Client was sent to the ER; No fracture or dislocation found. Client was placed on self-harm precautions.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Accidental Injury, Notice of Incident
- Accidental Injury
- Client hurt his ankle while playing basketball and complained of pain and swelling. Client was sent to the ER and diagnosed with an ankle sprain.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Personnel Record Review, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 10am – 1pm; Census: 56. Licensing reviewed 10 personnel files with no licensing concerns noted.
PRLU or OLTC
Notice of Incident, Peer Altercation
- Peer Altercation
- Client and peer were in an altercation, during which peer grabbed a pencil and stabbed client in the L and R forearm. Client was sent to the ER and diagnosed with laceration to both forearms. Resident was placed on assault precautions and peer restricted.
- Licensing follow-up: Licensing requested camera footage on 01/09/23; Staff reported the camera footage had cycled out, and there were no witness statements. Facility informed licensing that staff did separate the residents, and client’s wounds were superficial and did not require sutures. Residents are only allowed golf size pencils on the units. Client was discharged from facility on 01/25/23.
PRLU or OLTC
Accidental Injury, Notice of Incident
- Accidental Injury
- Client hurt his ankle while playing basketball in the gym. Client was sent to the ER and diagnosed with an ankle sprain.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Buildings and Grounds, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 12:30pm – 1:30pm; Census: 58. Walkthrough completed of the following areas: Education building, stations 1 & 2, gym and the cafeteria. Licensing spoke with staff regarding repairs made to the building. Windows have been replaced and the exterior doors have double magnets.
PRLU or OLTC
Notice of Incident, Self-Injury, Visit Compliance Report
- Self-inflicted Injury
- Client reported he swallowed 2 staples. Client was taken to the ER; X-ray revealed foreign body of alimentary tract, and client was instructed to return to the ER in 2-3 days to identify if the item had passed. Client was placed on suicide precautions.
- Licensing follow-up: Client got the staples from a classroom. Staff reported the teachers have been made aware for staples to be kept out of view of residents and that residents are not allowed behind or around teachers’ desks. Staff reported daily walk-throughs of facility are conducted, and black tape has been placed on the floor to mark how close residents are allowed to teacher’s desk.
PRLU or OLTC
Complaint Survey with POC, Revisit Survey with POC
- Complaint #AR000029294 was in compliance.
- Regs out of compliance –
- N134 – Failed to ensure that a physician’s order for a physical restraint was obtained and documented for 1 client.
- POC – All nursing employees will be re-educated by the DON on ESI documentation standards, ESI packets will be reviewed daily, facility will report ongoing compliance rates during daily leadership meeting, and a physician’s order was obtained and documented on 12/19/22 for client 1.
- A revisit was conducted on 03.30.23, and the facility was still not in substantial compliance with the following participation requirements:
- N142 – Facility failed to ensure an order for a physical and chemical restraint was not received at the same time for 3 clients and a physical restraint was utilized long enough to determine its effectiveness before the administration of a chemical restraint for 1 client.
- POC – Facility will conduct mandatory re-education in-service for all RNs and LPNs led by the DON (ESI Documentation, Obtaining and Documenting Physician Orders, Physician Transcribing and Authentication Policy, ESI Policy). Daily chart audits will be conducted, DON will discuss daily compliance rate in Quality/Safety Meeting, and compliance rates will be documented/submitted in monthly Quality Patient Dashboard.
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PRLU or OLTC
Notice of Incident, Peer Altercation, Visit Compliance Report
- Peer Altercation
- During an altercation with a peer, client was hit in the head by a desk. Client complained of pain to head area, with slight swelling and redness noted. Client was sent to the ER and diagnosed with contusion of scalp and head injury. Resident was placed on assault precautions and peer restrictions.
- Licensing follow-up: Staff reported the incident happened in the classroom, and the camera in the classroom is not working. Facility reported that administration was not made aware of resident being transported to the ER until 12/16/22 when reviewing incidents. Licensing interviewed client on 01/06/23, who reported he was attacked by his peer because he was crying, and he was then taken out of the room by staff and escorted to the nurse. Client has recovered from the injury with no complaints.
PRLU or OLTC
Notice of Incident, Sexual Contact, Visit Compliance Report
- Peer Sexual Contact
- Client reported that while in their assigned room, peer pushed him on the bed and started humping him from behind (with clothes on). Client was assessed with no injury or complaints. Peer was assigned single room placement and peer restricted, and both residents were seen by their therapist. There is no camera footage due to incident taking place inside their room.
- Licensing follow-up: Licensing received witness statements from both residents. Peer stated they were horseplaying, he pushed client on the bed and his leg wrapped around his, causing him to fall on client. Licensing spoke with staff, who stated the residents interactions are being monitored by staff.
PRLU or OLTC
Accidental Injury, Notice of Incident
- Accidental Injury
- Client complained of hurting his finger while playing basketball. Client was sent to the ER and diagnosed with contusion of finger. No new orders or prescriptions were given.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Medical, Notice of Incident
- Medical
- Client complained of abdominal pain and was taken to the ER. Client was diagnosed with abdominal pain, and no new prescriptions or orders were given.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Medical, Notice of Incident
- Medical
- Client was taken to the ER after having seizure-like activity. Client was diagnosed with generalized anxiety disorder, and no new prescriptions or orders were given.
- Licensing follow-up: No licensing concerns noted.