Complaint #AR00027599 unsubstantiated.
PRLU or OLTC
Complaint Survey
PRLU or OLTC
Personnel Record Review, Visit Compliance Report
Specialist reviewed personnel records for 5 staff members. No licensing concerns noted.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Client reported to staff that his roommate made him have sex with him on 1/14/22.
- Child Abuse Hotline was called and accepted. Client was taken to the ER for evaluation and facility made room changes so the residents would no longer share a room. Specialist followed up on 1/18/22 for investigation details and reviewed video footage on 1/26/22. Specialist determined staff was not providing the level of supervision necessary to ensure the safety and wellbeing of the residents. Staff can be seen out of staff/child ratio on two separate shifts throughout the night. Specialist emailed investigator for update on 2/9/22; No further details.
PRLU or OLTC
Notice of Incident
- Elopement
- Client eloped after climbing a fence, gaining access to the roof, and jumped off the front entrance to the building. Staff pursued the client on foot and local PD was called.
- Specialist was at agency conducting walkthrough when elopement occurred. Specialist spoke with client (after elopement) who stated he was angry because he had not followed instructions and staff had taken his Pokémon cards away as punishment.
PRLU or OLTC
Visit Compliance Report
- Completed buildings and grounds walkthrough and reviewed MARs. Census 57.
- Elopement was in progress at time of visit; Police were notified, and resident returned to facility during visit. The resident eloped over an unused fence located by the gym door. Maintenance stated they would contact fencing companies to discuss adding fencing around the area.
- Regs out of compliance –
- R910.1 – Please ensure the AC unit in room 305 is secured back to wall and the magnetic lock on the 300 outer hall door is covered (cover currently broken off exposing wires). Both corrected on 12/16/21.
- R913.5 – Rooms 405, 108, and 102 need clean sheets on the beds (visible dirt and debris on the sheets). Corrected on 12/16/21.
- Regs not correctable –
- R908.8 – Medication for 2 residents was marked as given at 14:00 and 16:00 on 12/16/21 (it was only 12:30pm).
PRLU or OLTC
Notice of Incident
- ER Visit (Testicle Pain)
- Client complained of pain to testicle area and was taken to ER.
- Specialist followed up on 12/15 for update on client’s condition. Staff reported the client is doing fine now and has expressed no pain/discomfort since the incident.
PRLU or OLTC
Technical Assistance, Visit Compliance Report
Specialist provided TA to all staff during 3 separate groups throughout the day regarding the 900 section of the Minimum Licensing Standards. Specialist discussed updates to the buildings and grounds per the Corrective Action Agreement and received copy of the December Program schedule for the residents.
PRLU or OLTC
Notice of Incident
- ER Visit (Passed Out)
- Client presented to nursing staff quiet, drowsy, and slow to respond. Client stated he thinks he passed out. Client taken to ER for evaluation. No follow-up details.
PRLU or OLTC
Notice of Incident
- ER Visit (Self-Harm)
- Resident was taken to ER after complaining of pain to his left hand after he hit a wall in the quiet room. No follow-up details.
PRLU or OLTC
Notice of Incident
- ER Visit (Peer Assault)
- Resident was attacking staff when he was placed in a restraint hold by staff. Two peers then attacked resident while he was in the restraint hold. Resident was taken to ER.
- On 12/9/21, specialist viewed video footage at facility and discussed with staff. No licensing concerns were noted, but specialist advised staff to remind all staff that they should respond immediately to an escalated child by removing any bystanders from the area.
PRLU or OLTC
Notice of Incident
- ER Visit (Side Pain)
- During room checks by staff, client was found lying on his mattress complaining of pain to his right side and difficulty moving. Nurse evaluated and resident was transported to ER. Resident was returned to facility by staff with no new orders; Client was instructed to take OTC pain medication and follow up with PCP.
- On 11/29/21, specialist followed up with facility via email for resident’s status; Facility reported the resident is now doing well and reports no pain or discomfort to staff.
PRLU or OLTC
Complaint Survey with POC, Revisit Survey
- Complaint #AR00027464 substantiated.
- Regs out of compliance –
- N 126 – Facility failed to ensure a restraint was not used as discipline for 1 resident who was physically restrained.
- N 132 – Facility failed to ensure an ESI was used in a safe manner and appropriately for the severity of the behavior for 1 resident who was physically restrained.
- Plan of Correction –
- Re-training, ESIs will be reviewed weekly, ESI/Incident tracker implementation, and quarterly training.
- A revisit was conducted on 12/29/21 for all deficiencies cited on 11/23/21. All deficiencies have been corrected, and no new noncompliance was found.
PRLU or OLTC
Visit Compliance Report
- Completed buildings and grounds walkthrough, reviewed MARs for 2 SRU residents and 2 PRTF residents. Specialists reviewed camera footage from incident and discussed steps the agency is taking to ensure the safety of residents.
- Regs out of compliance –
- R1011.7 – Room 204 AC unit screen is detached from the wall. Corrected 11/23/21.
- R1012.3 – Sink in bathroom of SRU unit is not functioning and faucet is detached from the sink base. Corrected 11/23/21.
- R911.6 – Light switch in room 104 has a missing screw and is detached from the wall. Corrected 11/23/21.
PRLU or OLTC
Notice of Incident
- ER Visit (Peer Altercation)
- Resident was transported to ER after he sustained injury during an altercation with peer.
- Child Abuse Hotline was called, not accepted. Specialist emailed staff about incident due to it being called into the hotline. Staff confirmed this was a child-on-child altercation that was called into the hotline by mistake. It was not accepted for investigation.
PRLU or OLTC
Notice of Incident
- ER Visit (Peer Altercation 1)
- Resident was transported to ER after altercation with several peers. Resident complained of right elbow pain.
- Specialist emailed staff for x-ray result and extent of altercation; Staff reported it was not a large-scale altercation and involved a total of 5 residents.
PRLU or OLTC
Notice of Incident
- ER Visit (Peer Altercation 2)
- Resident was transported to ER after he reported that his head was pushed to floor by peer during altercation. No follow-up details.
PRLU or OLTC
Notice of Incident
- ER Visit (Accidental Injury)
- Resident was transported to ER after he reported right ankle pain resulting from a fall he had outside while playing. No follow-up details.
PRLU or OLTC
Notice of Incident
- ER Visit (Self-Harm)
- Resident was transported to ER after he punched a brick wall and hurt his hand.
- Specialist requested the x-ray result from staff; X-ray showed to be negative
PRLU or OLTC
Notice of Incident
- ER Visit (Peer Altercation 1)
- Resident was transported to ER after he reported that he passed out and lost consciousness during a large-scale altercation at facility.
- On 11/18/21, specialist visited the facility and reviewed video footage of the incident involving multiple residents and staff. Due to the scale of the altercation, it was determined that staff had done everything within their ability to provide care to residents.
PRLU or OLTC
Notice of Incident
- ER Visit (Peer Altercation 2)
- Resident was transported to ER after he was attacked by multiple peers during large-scale altercation at facility.
- On 11/18/21, specialist visited the facility and reviewed video footage of the incident involving multiple residents and staff. Due to the scale of the altercation, it was determined that staff had done everything within their ability to provide care to residents.
PRLU or OLTC
Notice of Incident
- ER Visit (Peer Altercation 3)
- Resident was transported to ER after he injured his right foot in an altercation with several peers.
- On 11/18/21, specialist visited the facility and reviewed video footage of the incident involving multiple residents and staff. Due to the scale of the altercation, it was determined that staff had done everything within their ability to provide care to residents.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Licensing received report that staff member pushed client’s head into the ground during a restraint hold causing injury.
- Child Abuse Hotline was called and accepted. Staff member was placed on immediate suspension pending investigation results. Specialist met with investigator on 11/18/21, reviewed camera footage, assisted with interviews of staff, and reviewed all documentation of the restraint hold. No further details.
PRLU or OLTC
Notice of Incident
- Elopement (1)
- Resident walked through an unlocked gate during recreation time outside the facility and eloped from property. Police were notified.
- Specialist followed up with facility on 11/18/21 in person; No further details.
PRLU or OLTC
Notice of Incident
- Elopement (2)
- Resident walked through an unlocked gate during recreation time outside the facility and eloped from the property. Police were notified.
- Specialist followed up with facility on 11/18/21 in person; No further details.
PRLU or OLTC
Notice of Incident
- Elopement (3)
- Resident eloped from facility through an unlocked gate during recreation time outside. Police were notified.
- Specialist reviewed the incident on 11/19/21 and discussed incident with staff via email. Due to the failure of staff to secure the gate and reported failure to appropriately supervise the resident the agency will receive a citation for standard R907.2