- Accidental Injury
- Client was taken to the ER after complaining of right hip pain from playing kickball outside. No follow-up details.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Accidental Injury, Notice of Incident
PRLU or OLTC
ER Visit, Notice of Incident
- ER Visit (Accidental Injury)
- Client was taken to the ER after complaining of hip pain from playing kickball outside. Diagnosis: Contusion to right side of back. Client will follow-up with PCP if symptoms persist. No follow-up details.
PRLU or OLTC
ER Visit, Notice of Incident
- ER Visit (Ingested Hand Sanitizer 1)
- Client admitted to drinking hand sanitizer, a Kool-Aid single pack, and water. Client was taken to the ER. Diagnosis: Encounter for observation for suspected toxic effect from ingested substance ruled out. Facility will remove bottled sanitizer from each classroom and install sanitizer dispensers for all classrooms near the entrance door by 8/19/22.
- Licensing follow-up: Specialist observed each classroom on 8/25/22. All hand sanitizer bottles were removed from each classroom and dispensers will be installed by 9/2/22.
PRLU or OLTC
ER Visit, Notice of Incident
- ER Visit (Ingested Hand Sanitizer 2)
- Client reported drinking hand sanitizer, a Kool-Aid single pack, and water. Client was taken to the ER. Diagnosis: Encounter for observation for suspected toxic effect from ingested substance ruled out. Facility will remove bottled sanitizer from each classroom and install sanitizer dispensers for all classrooms near the entrance door by 8/19/22.
- Licensing follow-up: Specialist observed each classroom on 8/25/22. All hand sanitizer bottles were removed from each classroom and dispensers will be installed by 9/2/22.
PRLU or OLTC
ER Visit, Notice of Incident
- ER Visit (Allergic Reaction)
- Client sent to ER for potential allergic reaction to medication. Diagnosis: Allergy status to other drugs, medicaments, and biological substances. Continuance of care to follow-up with prescribing physician.
- Licensing follow-up on 8/18/22: Medication adjustment.
PRLU or OLTC
Children's Records Review, Self Report Visit, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility cited (907.2) regarding 8/5/22 incident; The corrective action plan took place on 8/10/22. Staff involved will receive progressive disciplinary actions up to termination, additional training on supervision, and head counting before and after transitions by the Clinical Director. Specialist viewed camera footage from 8/5/22 and observed resident coming from behind bedroom after staff had checked the bedroom.
- Specialist viewed 6 residents files. One resident did not have a master treatment plan completed in 30 days.
- Regs out of compliance –
- 9.907.2 – Child caring staff shall be responsible for providing the level of supervision, care, and treatment necessary to ensure the safety and well-being of each child at the facility, taking into account the child’s age, individual differences and abilities, surrounding circumstances, hazards and risks.
- 9.903.4 – The treatment plan shall be developed within thirty days after placement.
PRLU or OLTC
ER Visit, Notice of Incident
- ER Visit (Passed Out, Hit Head)
- Client passed out during medication pass and fell, hitting head on floor. Client was transported to ER. Continuance of care through nurses and APRN.
- Licensing follow-up on 8/8/22: Ibuprofen and Acetaminophen for medication. Further diagnostic work up recommended if condition worsens.
PRLU or OLTC
ER Visit, Notice of Incident
- ER Visit (Neck Pain, Involuntary Movements)
- Client complained of involuntary neck movement and pain. It was reported that client was not doing anything before the incident. Client was taken to the ER and diagnosed. No follow-up details.
PRLU or OLTC
Maltreatment, Notice of Incident
- Maltreatment
- Client was left unsupervised from 8:33am – 9:56am. During transition to outside activity, the client stepped out of line and hid behind bedroom door. Camera footage was reviewed, and nursing assessed client. Staff involved will receive progressive disciplinary actions, additional training on supervision, and head counting before and after transitions. Staff will not work in direct contact with any residents and work business hours when facility administrators are present pending investigation.
- Child Abuse Hotline was called, accepted on 8/8/22 (initially not accepted); Investigation pending. Licensing follow-up: 8/10/22, staff involved will be trained by the Clinical Director before their work shift.
PRLU or OLTC
Notice of Incident
- Client jammed middle finger while playing basketball; Swelling noted. X-ray was scheduled.
- Licensing follow-up: Copy of x-ray received.
PRLU or OLTC
Notice of Incident
- X-ray (Finger Pain)
- Client complained of pain in right index finger; No swelling or edema noted. X-ray: No findings were noted. No follow-up details.
PRLU or OLTC
Buildings and Grounds, Visit Compliance Report
- Licensing Specialist: Not listed.
- The following areas were observed: Hall 100 bedrooms, dayrooms, classrooms 1-4 in the school, dining room. MARs checked for multiple residents.
- TA –
- 9.911.6 – All buildings and furnishings shall be safe, clean, and in good repair.
PRLU or OLTC
Children's Records Review, Personnel Record Review, Visit Compliance Report
- Licensing Specialist: Not listed.
- Facility visited from 10:00am – 12:30pm. Two client records reviewed: One client missing a social security card copy. No correspondence could be found in file documenting attempts to retrieve SS card. Five personnel records reviewed: One staff member did not have 3 letters of reference.
PRLU or OLTC
Elopement, Notice of Incident
- Elopement
- Client eloped from administration building after kicking through exit doors. Staff pursued client and maintained visual throughout the incident. No follow-up details.
PRLU or OLTC
Consensual Sexual Contact, Notice of Incident
- Sexual Contact (Consensual)
- Client reported consensual sexual contact with roommate that occurred a few weeks ago inside their room. Client was reassigned to a new room, separating each youth on opposite ends of the milieu and placed on peer restriction from one another. A sexual safety plan has been implemented.
- Licensing follow-up on 07/11/22: Licensing inquired if the hotline was called. The agency reported they did not due to the sexual contact being consensual. Licensing explained this should be reported due to the residents being underage and placed in a facility that requires a high level of supervision. Licensing confirmed there was no date of the incident, so camera footage would not be reviewed. Child Abuse Hotline was called, not accepted.
PRLU or OLTC
ER Visit, Notice of Incident
- ER Visit (Peer Altercation)
- Client was stabbed in the left shoulder and right hand during an altercation with peer. Client received immediate first aid and sent for consultation with APRN.
- Licensing follow-up on 07/06/22: In response to request for further information, the facility reported the peer used a pen to stab client.
PRLU or OLTC
Buildings and Grounds, Visit Compliance Report
- Licensing Specialist: Not listed.
- Buildings & Grounds conducted from 9am – 10am. Census: 44. Covid positive client quarantined in 300 Hall, and 1 staff on leave with Covid. Hall 400, cafeteria, and gymnasium checked. MARs checked for multiple residents. No licensing concerns noted.
PRLU or OLTC
Notice of Incident, Sexual Misconduct
- Sexual Misconduct
- Upon camera review, client was seen masturbating on the outside of their pants while looking at roommates who appeared to be sleeping. Client then exposed themselves and continued to masturbate while looking at roommates until staff approached the room for 15-minute observation checks. The client was reassigned to a single room and a sexual safety plan implemented. No follow-up details.
PRLU or OLTC
ER Visit, Notice of Incident
- ER Visit (Peer Altercation)
- Client was bitten by a peer during an altercation. Client was taken to the ER.
- Licensing follow-up on 6/22/22: Emailed the facility requested further information on safety precautions put in place to separate the residents. Facility reports the peers were placed on peer restriction.
PRLU or OLTC
ER Visit, Notice of Incident
- ER Visit (Peer Altercation)
- Client reported pain to hand and wrist after punching a peer in the head. Client was taken to the ER.
- Licensing follow-up on 6/22/22: Emailed the facility requested further information on safety precautions put in place to separate the residents. Facility reports the peers were placed on peer restriction.
PRLU or OLTC
Visit Compliance Report
- Licensing Specialist: Clayton DeBoer.
- Facility visited from 12:00pm – 1:00pm. Census: 47. MARs reviewed for 5 residents. No licensing concerns noted during visit.
PRLU or OLTC
ER Visit, Notice of Incident
- ER Visit (Hand Pain 1)
- Client complained of lateral pain to hand. Client did not communicate the cause of pain with staff. Client was taken to the ER for an x-ray.
- Licensing follow-up: The facility notified licensing via email that there would be an incident report on 6/10/22, but there was an issue with their email system that would not allow for attachments to be sent. Licensing did not receive the final incident report until 6/14/22.
PRLU or OLTC
ER Visit, Notice of Incident
- ER Visit (Hand Pain 2)
- Client complained of pain to hand, 4th digit. Client stated the pain was caused from a previous incident but did not specify. Client was taken to the ER for an x-ray.
- Licensing follow-up: The facility notified licensing via email that there would be an incident report on 6/10/22, but there was an issue with their email system that would not allow for attachments to be sent. Licensing did not receive the final incident report until 6/14/22.
PRLU or OLTC
ER Visit, Notice of Incident
- ER Visit (Sore Throat, Dizzy, Diarrhea)
- Client complained of sore throat, dizziness, and diarrhea to the APRN. Client was taken to the ER for a chest x-ray.
- Licensing follow-up: The facility notified licensing via email that there would be an incident report on 6/10/22, but there was an issue with their email system that would not allow for attachments to be sent. Licensing did not receive the final incident report until 6/14/22.
Medicaid Inspection of Care
Inspection of Care Report
- Included: IOC Report, CAP
- This additionally ordered inspection was triggered by a report made to DPSQA pertaining to the facility regarding elopements, broken windows, children complaining about pain, medication administration, peer on peer fights, and five pending maltreatment investigations.
- Multiple deficiencies noted. Plan of Correction required to be completed within 30 days.