- 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
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.
PRLU or OLTC
Notice of Incident
- Elopement (2)
- Client eloped from facility after magnetic doors failed due to complications from the ice storm. Police were notified of elopement.
- Specialist visited facility on 3/3 and discussed incident with staff. Specialist reviewed camera footage; No licensing concerns noted.
PRLU or OLTC
Corrective Action Agreement
- Non-compliance areas cited during the past six months:
- 911.6 (Buildings) – All buildings and furnishings shall be safe, clean, and in good repair.
- 908.8 (Health and Medical) – The administering of all medications, including over the counter, shall be logged at the time the medication is given, by the person administering the medication.
- 907.2 (Ratio and Supervision) – 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.
PRLU or OLTC
Notice of Incident
- Elopement
- Client eloped from facility after climbing gate and gaining access to the roof. He climbed down the front of the building and eloped on foot. Local PD were immediately notified.
- During licensing visit on 2/18, Specialist discussed multiple elopements occurring where client’s used gate to gain access to the roof. Staff reported they will look into removing the gate and adding an additional fence further out from the building to prevent residents from gaining access to the roof.
PRLU or OLTC
Licensing Compliance Record
- Licensing Specialist: Chelsea Vardell.
- Licensing reviewed 2 incidents that were reported late. Education was provided to the nurse to ensure that she understands what incidents need to be reported to the Licensing Unit.
- TA –
- R110.17 – 01/25/22 and 01/27/22 incidents were not sent to Licensing until 01/31/22.
PRLU or OLTC
Notice of Incident
- ER Visit (Peer Altercation)
- Client was transported to ER after complaining of pain resulting from altercation with peer. Client received CAT scan at ER. No follow-up details.
PRLU or OLTC
Notice of Incident
- ER Visit (Peer Altercation)
- Client was taken to ER for hand examination after altercation with peer. No follow-up details.
PRLU or OLTC
Notice of Incident
- Injury (Accidental Injury)
- Client hurt wrist while playing outside and was taken to ER for an x-ray.
- Specialist emailed facility on 2/9 to determine the results of the x-ray.
PRLU or OLTC
Buildings and Grounds, Visit Compliance Report
- Licensing Specialist: Chelsea Vardell.
- Census: 58. Licensing conducted afterhours walkthrough of all units and dayrooms from 18:18 – 19:32. Random rooms were viewed on all 4 units. MARs reviewed for 7 residents. Licensing discussed areas of concerns and ratio issues with staff, and CEO reported new staff for evening shifts have been hired and will be in orientation this week.
- Regs out of compliance –
- R912.4 – Station 2 bathroom had urine on toilet seat and floor (due 02/07/22). Station 2 bathroom shower stall had visible mold on the ceiling (due 02/11/22).
- R911.6 – Pile of trash and discarded dinner plates with food were seen piled in the corner of 200-hall unit. Staff reported they did not have a trash can or trash bag to dispose of the trash; Staff was given a trash bag to clean up the trash immediately (corrected 02/07/22).
- R911.15 – MARs on Station 2 had 7 medication entries that were not initialed for residents (due 02/08/22).
- R911.10 – Bedrooms on 400 hall were warm and the thermostat showed them at 86 degrees. Staff reported they will call the on-call maintenance staff to come in and adjust the bedroom units tonight (corrected 02/07/22).
- Regs not correctable –
- R907.3 – Staff to child ratio was out of compliance in 3 areas (Station 2 dayroom 1:15, 300 Hall dayroom 2:16, 400 Hall dayroom 2:14).
PRLU or OLTC
Notice of Incident
- ER Visit (Self-inflicted Injury)
- Client became upset after verbal altercation with peer and punched a plexiglass window in the dayroom, breaking it and sustaining minor cuts on his hand. Client was taken to ER.
- Specialist emailed facility on 2/7 to request results of x-ray; X-ray results were received and note no dislocations or fractures.
PRLU or OLTC
Notice of Incident
- ER Visit (Peer Altercation)
- Client complained of elbow pain after altercation with peer. Client taken to ER.
- Specialist emailed a 521 to facility on 2/7 to provide technical assistance for the late reporting of this incident (Specialist received incident on 1/31).
PRLU or OLTC
Notice of Incident
- ER Visit (Accidental Injury)
- Client complained of hand pain after horseplaying with peers. Client taken to ER.
- Specialist emailed a 521 to facility on 2/7 to provide technical assistance for the late reporting of this incident (Specialist received incident on 1/31).
PRLU or OLTC
Notice of Incident
- Maltreatment
- Report was made that staff member pushed client twice while in the school classroom.
- Child Abuse Hotline was called, not accepted. Staff was immediately suspended pending the results of the investigation. Specialist reviewed video on 1/26/22 and was able to see staff placing her hand on the resident’s shoulder and push him away to gain personal space as he was trying to get past her to leave the room. Staff did not injure the resident and staff was counseled on how to appropriately gain personal space.
PRLU or OLTC
Visit Compliance Report
- Buildings and grounds conducted, and MARs reviewed for 3 residents. Census: 60.
- Regs out of compliance –
- R912.4 – Mold was seen on the wall in 2 shower stalls located in the bathroom by Nurse Station 1. Staff reported that they will bleach the area and investigate further.
- R1011.7 – A/C unit was detached from the wall in 200 hall dayroom and in bedroom 204. Staff secured dayroom A/C on site and will have to determine how to secure bedroom A/C due to how it was broken.
- R913.5 – Pillow in room 103 was tattered and in very poor condition. The pillow was removed by staff and staff reported it would be replaced with a new one.
PRLU or OLTC
Notice of Incident
- ER Visit (Leg Cramps)
- Client complained of loss of feeling in his legs; Client was taken to ER and diagnosed with leg cramps. The issue continued so staff took client to different ER for second opinion (LeBonheur Children’s Hospital). No follow-up details.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Client reported to his therapist on 01/25/22 that he was slapped by staff member during a restraint hold that took place on 1/17/22.
- Child Abuse Hotline was called and accepted. Staff was placed on administrative duties only and will have no direct or unsupervised contact with residents pending investigation results. Specialist reviewed camera footage on 1/26/22 and determined the restraint hold was done correctly and client was not slapped by staff. CACD investigation was closed as unsubstantiated as of 2/9/22.