- Elopement
- Client used extreme force to open the door to the administration building, kicking it open to elope from facility. Staff followed client off campus and continued to process with him. No follow-up details.
PRLU or OLTC
Notice of Incident
Police Report
Battery Third Degree
Staff member reported that while she was trying to detain a juvenile from harming himself, she was attacked. She advised she was kicked in the face and punched multiple times by the juvenile. Juvenile was placed into a quiet room; No visible injuries to staff member.
PRLU or OLTC
Visit Compliance Report
- Licensing Specialist: Chelsea Vardell.
- Census: 62. Specialist conducted visit from 1120 – 1330, reviewed MARs for 3 residents.
- Regs out of compliance –
- R911.6 – A/C unit covers were detached in room 105, dayroom 1: B and large dayroom station 2 (Due date 4/1/22). Specialist was made aware that 3 bedrooms flooded the previous day from the large amount of rain that occurred. The rooms filled with rainwater coming from the vents on the A/C units. The residents were placed in the dayrooms to sleep that night and the water was currently being cleaned and dried out. Maintenance was working on how to prevent this from occurring again.
PRLU or OLTC
Notice of Incident
- Elopement 1
- Client was informed by peer that they had retrieved a badge that had fallen to the ground, and they used it to elope from facility. Local law enforcement was notified.
- Specialist followed up on 3/30 requesting additional information regarding any retraining done with the staff whose badge was used in the elopement.
PRLU or OLTC
Notice of Incident
- Elopement 2
- Client found a staff’s badge on the ground and used it to elope from facility. Staff’s badge fell off while staff member was intervening in a fight between other residents. Local law enforcement was notified.
PRLU or OLTC
Visit Compliance Report
- Licensing Specialist: Chelsea Vardell.
- Census: 64. Specialist conducted facility visit from 1120 – 1300, reviewed MARs for 3 residents.
- Regs out of compliance –
- R911.15.f – Strings found in pants in the bedroom of 108 (Corrected on-site).
- R911.6 – A/C unit cover was seen detached from the wall in bedroom 108 and Station 1 big dayroom wall was seen to have a 14–16-inch section missing drywall (Due date 3/31/22).
- R913.5 – Wooden bunk bed is peeling exposing sharp pieces of wood that the specialist was able to remove by hand in room 103 (Due date 3/26/22).
PRLU or OLTC
Notice of Incident
- ER Visit (Accidental Injury)
- Client taken to ER for pain in his right foot/toe area due to an elopement attempt a previous day, in which he tried to jump a fence. No follow-up details.
PRLU or OLTC
Notice of Incident
- ER Visit (Finger Pain)
- Client taken to ER after complaining of pain to 3rd finger of his left hand. No follow-up details.
PRLU or OLTC
Notice of Incident
- ER Visit (Headache, Sore Throat)
- Client taken to ER after complaining of headache and sore throat. Client’s temperature elevated.
- Specialist followed up on 3/23/22 for client’s strep test results: Staff reported the test was negative.
PRLU or OLTC
Notice of Incident
- ER Visit (Sore Throat)
- Client taken to ER for sore throat. Client’s throat appeared red/swollen at examination and temperature was 103.6. No follow-up details.
PRLU or OLTC
Notice of Incident
- ER Visit (Self-inflicted Injury)
- Client taken to ER after complaining of right-hand pain due to punching a wall the day before. Mild swelling noted. No follow-up details.
PRLU or OLTC
Notice of Incident
- ER Visit (Peer Altercation)
- Client was involved in confrontation with peer and punched peer. Client reported pain/swelling to right hand and was taken to ER for x-ray.
- Specialist followed up on 3/21 for client’s x-ray results: No acute findings.
PRLU or OLTC
Visit Compliance Report
- Census: 61. Two residents in quarantine due to positive flu cases. MARs reviewed for multiple residents.
- A fence in the courtyard was bent and damaged from an ice storm and is in the process of being fixed (fence is still intact but bent over). Painting in the process on the school hall and painting completed in the unit halls. Trim still being replaced in the facility, but they ran out of material and will be getting more next week to finish the replacement. Facility reported they are in the process of getting a plumber to correct plumbing issues, but the contracted agency failed to comply with facility rules and was denied the contract. The facility is in search of a new plumber. Facility is also inquiring about new doors and magnetic locks for the agency.
PRLU or OLTC
Notice of Incident
- ER Visit (Accidental Injury)
- Client taken to ER due to complaining of pain to his 5th finger on the right hand. Client reported he thinks he injured it the night before while playing with peer.
- Specialist followed up on 3/21 for client’s x-ray results: No acute findings.
PRLU or OLTC
Notice of Incident
- ER Visit (Covid-19 Symptoms)
- Client taken to ER for chest x-ray due to complaining of coughing, shortness of breath, wheezing, and a headache. Client’s COVID and flu test came back negative.
- Specialist followed up on 3/21 for client’s x-ray results; Results sent to specialist.
PRLU or OLTC
Notice of Incident
- ER Visit (Muscle Pain)
- Client taken to ER after reporting muscle pain and neck stiffness. Muscle rigidity was noted by facility nurse. No follow-up details.
PRLU or OLTC
Notice of Incident
- ER Visit (Self-inflicted Injury)
- Client taken to ER due to pain in his fifth digit of his left hand from hitting a wall.
- Specialist followed up on 3/15 to inquire about pending x-ray results.
PRLU or OLTC
Notice of Incident
- ER Visit (Seizure)
- Client taken to ER due to having a seizure on the unit. No follow-up details.
PRLU or OLTC
Notice of Incident
- Disturbance
- Multiple residents on the 100-hall attempted to bust down the door and elope from the facility. Due to the number of residents attempting to elope, the police were notified and arrived on scene to assist staff.
- Specialist visited the facility on 3/10 to review video footage from the incident. No licensing concerns noted.
PRLU or OLTC
Notice of Incident
- ER Visit (Pain, Vomiting)
- Client taken to ER after having pain and vomiting. Client had an outpatient surgery earlier in the day, so he was taken out of precaution. No follow-up details.
PRLU or OLTC
Visit Compliance Report
- Census: 61. Visit conducted; Specialist reviewed 4 children’s records.
- Regs out of compliance –
- R904.1.h – No birth certificate in the chart for 1 resident or documentation by staff showing attempts to receive a copy of birth certificate. (Due Date: 4/4/22)
- Regs not correctable –
- R905.12 – There was no physician order in the chart for a physical restraint hold initiated on 1 resident dated 11/13/21.
PRLU or OLTC
Notice of Incident
- ER Visit (Peer Altercation)
- Client taken to ER after peer slammed his head into the floor causing it to bleed.
- On 3/4, Specialist requested the report be broken into 2 incident reports as it had more information about other events. On 3/10, Specialist reviewed camera footage and noted staff did not properly intervene or attempt to prevent the peer from attacking client. Facility cited for R1007.2. Staff involved will be retrained on how to retrain and redirect residents during an altercation.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Staff member allegedly told residents “you better get him”, in reference to client being disruptive on the unit at bedtime. This resulted in the client being attacked by a peer. Client received 3 staples in his head at ER.
- Child Abuse Hotline was called and accepted. Alleged staff member was notified and informed that she would not be allowed to return to work pending the results from investigation. Specialist requested video footage be retained on 3/4/22, and visited facility on 3/10/22 to sit in on investigator interviews with resident witnesses. Residents report they did not hear staff member say anything, but one witness did report that he feels staff member did not help client and instead stood back and let it happen. After camera review, specialist determined that 3 staff did not provide the level of supervision and care to ensure the safety of client. Two additional staff members interviewed reported that alleged staff said “Can you come get him” as she requested staff to come assist getting client out of the doorway. Staff reported the alleged staff member did not request for residents to assist.
PRLU or OLTC
Notice of Incident
- Injury (Peer Altercation)
- Client threw a tape dispenser at peer and was then placed in a restraint hold. While in the hold, several other residents began hitting/kicking the client. Client was taken to ER for evaluation of injuries.
- Specialist visited facility on 3/3. Specialist discussed incident with staff and reviewed camera footage of the incident for any licensing concerns.
PRLU or OLTC
Notice of Incident
- Elopement (1)
- Client eloped from facility after magnetic doors failed due to complications from the ice storm. Client was able to sneak out of his hall while staff were involved in another situation, then fled from the bathroom out the front door. Police were notified, but the resident was located and returned by staff approx. 1 hour later.
- Specialist visited facility on 3/3 and discussed incident with staff. Specialist reviewed camera footage for any licensing concerns.