Disability Rights Arkansas

Perimeter Behavioral of Forrest City / Woodridge of Forrest City

*Photos taken by DRA staff during onsite monitoring visits. Photos reflect the most recent conditions observed by DRA staff but may not reflect the current conditions at the facility. If you are associated with a facility and have updated information or photos you would like to share, please contact DRA at [email protected]

Location: Forrest City, AR

Population Served: Males ages 12-17 and a specialized sexual rehabilitative unit for males ages 12-17

# of residents per unit: Up to 21 Residents per room: 1-3 (SRU has 1 or 3, never 2) Capacity: 66

Contact with family (Calls and visit schedule): Calls 2x/week.

Restraint utilized? Yes Chemical Restraint utilized?  Yes Seclusion utilized? Yes 

Treatment Components:

Clinical Director - LPC-TA

Therapists: 3 full-time therapists (1 LCSW, 1 LPC, 1 LMSW); 2 part-time/contract therapists (1 LCSW ACSW, 1 LAC)

Treatment modalities offered: DBT, CBT, TF-CBT, Person-Centered, Narrative, Reality, Anger Replacement Therapy

# of individual therapy sessions/week: 1x/week

# of group therapy sessions led by a licensed mental health professional/week: 3x/week

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PRLU or OLTC

Visit Compliance Report

  • Specialist completed record check on 2 residents and reviewed MARs. Discussed Corrective Action Agreement progress; Facility reported all staff have completed SAMA and Intent Training. Staff provided list of employees for training documentation.
  • TA –
    • R902.10 – Resident in PRTF program did not have information documented as received upon admission. Documentation of all required information was provided to facility.
    • R1002.13 – Resident in SRU program did not have information documented as received upon admission. Documentation of all required information was provided to facility.
  • Regs not correctable –
    • R1003.11.d – Please ensure a plan is listed on the treatment plan for a resident in SRU program showing how the resident will continue medication management.
    • R1008.4.d – SRU resident did not have documentation that medication was given.
    • R908.9.d – PRTF resident did not have documentation that medication was given.
    • R1005.7 – There was no documentation of 7 restraints performed on resident (SRU) and no physician order for 1 chemical restraint used on resident. Staff reported the restraint justification packets cannot be located at this time. It is unknown if it was a failure to document or if the packets are misplaced. Risk Director and Director of Nursing are no longer employed at facility and replacement staff is due to begin 9/7.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client reported to his aunt on a phone call that on 8/31/21 he was slammed to the ground by staff member during a restraint hold. While in the restraint hold, staff allegedly grabbed the client’s penis and squeezed.
    • Staff member was placed on office duties only, with no access to work with any residents directly or unsupervised on 9/9/21. Child Abuse Hotline was called and accepted, unsubstantiated. Specialist reviewed restraint packet, nursing notes, witness statements, and discussed the interviews conducted. There is no video footage of the incident, and it was determined the restraint hold was justified as the resident was actively attacking staff.  

PRLU or OLTC

Visit Compliance Report

  • Completed buildings and grounds walkthrough of 100, 200, 300, and 400 hall and all dayrooms and bathrooms. Reviewed MARs of 2 residents.
  • Discussed what facility was doing in response to the Formal Corrective Action Plan put in effect: Staff are being retrained on SAMA, a sign in sheet showing completion of Intent training will be emailed to specialist, and staff provided specialist with August’s weekly schedules for residents.
  • Discussed report in which 2 residents allegedly had sexual contact on multiple occasions. The residents have both now denied sexual contact, but measures were taken to restrict peers from each other including moving them to separate bedrooms.
  • Regs out of compliance –
    • R911.15.f – Rooms 106, 303, and 401 had strings or articles of clothing with strings; Corrected 8/19/21.
  • Regs not correctable –
    • R908.8 – Medications (Clonidine & Buspar) were not given to a resident on 8/18/21, but there was no initials or notes explaining why. The nurse reported the resident was spotted pocketing his pills on this day and after a search was conducted, additional pills were found. The decision was made not to give the resident any further medications that night.

PRLU or OLTC

Notice of Incident

  • Elopement (2)
    • Six residents eloped from the facility by busting open the magnetic lock on door. Staff called the police department for assistance.
    • CEO of facility reported to Specialist that residents have discovered that if you kick open the door on the units, they will pop open allowing residents to elope. CEO has put in an order (that was approved) to add an additional magnetic lock to each of the unit doors. They should be installed within the next 2 weeks. In the meantime, staff will stand in front of the doors during transition times to ensure residents do not run at the doors.

PRLU or OLTC

Notice of Incident

  • Elopement (1)
    • Resident eloped again after he pushed by staff that was exiting door. The resident crawled under the fence, then squeezed through a gate. Resident stood across the road and yelled at staff. The police department was called.
    • CEO of facility reported to Specialist that the resident did not end up going to acute care and instead his DCFS came and removed him from the program.

PRLU or OLTC

Notice of Incident

  • Sexual Abuse
    • Reported to DCCECE on 8/10/21, date of incident unknown. Resident reported to his therapist that his roommate has been touching him sexually without his consent for several weeks.
    • Child Abuse Hotline was called and accepted, unsubstantiated. Residents placed on peer restrictions. Specialist visited facility to discuss the incident with staff; The resident has now recanted and both resident and peer report no sexual contact took place between them, but they continue to be on peer restriction.

PRLU or OLTC

Notice of Incident

  • Peer Altercation
    • Police were called when 2 separate altercations took place between residents and staff were concerned about the possibility of further escalation, so they called the police. Police spoke with residents/staff involved.
    • Upon Specialist’s follow-up, staff stated that staff was in ratio at the time of altercation, but there is no video footage of the incident due to the location. Staff explained a new staff member called the police instead of following proper procedure. The new staff has since been re-educated on how to properly handle an ESI.

PRLU or OLTC

Notice of Incident

  • Elopement
    • Two residents kicked open a door at the facility and took off on foot. Residents were found by the local police department and returned unharmed approximately 10 minutes after elopement.
    • In response to Specialist’s follow-up, staff reported the staff/child ratio was 1:6 at time of incident, there is no camera footage available, and attempts have been made/documented to contact the 2 residents’ out of state guardians.

Police Report

Theft of Property

Charge Nurse at facility stated that on 7/28/21, there were 5 half pills and 1 whole pill of Riddiline missing.

PRLU or OLTC

Notice of Incident

  • Complaint
    • Licensing Specialist spoke with legal guardian of resident at facility. The guardian discussed concerns about not being made aware of incidents, altercations, injuries, ER visits, or a recent positive Covid screening by the facility.

PRLU or OLTC

Notice of Incident

  • Complaint
    • Licensing Specialist received an email from a concerned mother who alleged that the facility was not giving her updates, information about her son placed at the facility, and is not allowing her to speak with him.
    • Licensing Specialist followed up resident’s DHS guardian and reviewed mother’s contact
      rights.

PRLU or OLTC

Notice of Incident

  • Other – Medication Tampering
    • A nurse found that a discontinued narcotic medication (Ritalin) belonging to a resident had been tampered with. The medication was removed from the blister packs, replaced with a second medication, and resealed using tape.
    • Facility is conducting drug screenings on all 9 staff that had access to the medication storage area.

PRLU or OLTC

Technical Assistance, Visit Compliance Report

Program Manager and Specialist met with facility CEO and Clinical Director to discuss surge in founded incidents at facility. Program Manager advised staff that they would be placed on a formal Corrective Action Agreement and discussed the requirements.

PRLU or OLTC

Notice of Incident

  • Maltreatment – Peer Altercation
    • The nurse noted a resident with 2 black eyes and a bruise on his forehead. Resident reported that he had been in an altercation with another resident and that staff watched without intervening to help him.
    • Staff was placed on suspension on 7/23/21 pending investigation results. Child Abuse Hotline was called and accepted.

PRLU or OLTC

Notice of Incident

  • ER Visit – High Temp and Painful Breathing
    • While doing assessments, nurse noted resident’s O2 SAT was at 92% and he had a temperature of 99.8. Resident complained of pain when he breathes. Resident was taken to ER for further evaluation.

PRLU or OLTC

Corrective Action Agreement

  • The following non-compliance areas have been cited during the past six months:
    • 905.4(g) The following actions shall not be used, including as discipline: (g) Physical injury or threat of bodily harm.
    • 905.9 Physical restraints shall be performed using minimal force and time necessary.
    • 911.6 All buildings and furnishings shall be safe, clean, and in good repair.

PRLU or OLTC

Notice of Incident

  • ER Visit – Self-inflicted Injury
    • Resident reported to the nurse that he was having pain in his right hand after punching a window in the 300 Hall on 7/18/21. Nurse noted swelling and discoloration of hand. Resident taken to ER for further evaluation.

PRLU or OLTC

Notice of Incident

  • ER Visit – Self-inflicted Injury
    • Resident reported to the nurse that he was experiencing pain in his right hand because he punched a wall in his room the morning of 7/18/21. Nurse noted discoloration to right hand. Resident was taken to ER for further evaluation.

PRLU or OLTC

Notice of Incident

  • ER Visit – Peer Altercation
    • Resident reported to the nurse that he was experiencing pain in his right forearm after hitting it on a wall during an altercation that took place with another resident on 7/17/21. Resident was taken to ER for further evaluation.

PRLU or OLTC

Notice of Incident

  • ER Visit – Self-inflicted
    • Resident complained to the nurse that he punched a wall and was experiencing pain in his right hand. Resident was sent to ER for x-ray of his hand.

PRLU or OLTC

Notice of Incident

  • ER Visit – Accidental Injury
    • Resident was outside playing with peers when he began to climb under and over a fence. The resident was then chased by another peer who had a stick, so he climbed the fence again and fell off hitting his head. Ambulance was called due to the resident hitting his head and complaining of severe knee pain.

PRLU or OLTC

Notice of Incident

  • ER Visit – Leg Pain
    • Resident was sent to ER after complaining of right leg pain with an unknown cause.

PRLU or OLTC

Notice of Incident

  • ER Visit – Accidental Injury
    • Resident was playing basketball when he hit a wall. Resident was taken to ER after complaining of collar bone pain.

PRLU or OLTC

Complaint Survey with POC, Revisit Survey, Workload Report

  • Complaint #AR00026765 unsubstantiated. Complaint #AR00026766 unsubstantiated. Complaint #AR00026840 unsubstantiated. Complaint #AR00026804 substantiated. Complaint #AR00026832 substantiated.
  • Regs out of compliance –
    • N 128 – Facility failed to ensure an injury did not occur during an ESI (Emergency Safety Intervention) involving a physical restraint for 2 clients.
    • N 143 – Facility failed to ensure a physician’s order for a chemical restraint was documented in the client’s record for 1 client.
    • N 154 – Facility failed to ensure the names of all staff physically participating in or providing assessments during an ESI were documented in the client’s record for 3 clients.
    • N 155 – Facility failed to ensure a cumulative log was maintained for each ESI for 4 clients.
    • N 188 – Facility failed to ensure all staff involved in an ESI were present during the client debriefing for 4 clients.
    • N 189 – Facility failed to ensure all staff involved in an ESI were present during the staff debriefing for 3 clients who had been physically restrained.
    • N 202 – Facility failed to ensure staff involved in ESI’s resulting in client injuries met with supervisory staff to evaluate the circumstances causing the injury and to develop a plan to prevent injury in the future for 2 clients.
    • N 214 – Facility failed to ensure staff ESI re-training was done after ESI resulted in injury for 2 clients.
  • Facility Plan of Correction –
    • Staff responsible for improper ESI on client #3 was suspended immediately and terminated on 7/6/21. Staff responsible for improper ESI on client #4 was suspended immediately and terminated on 7/7/21 (This staff member was the ESI instructor and program manager.) Re-training for Emergency Behavior Management techniques, ESIs (technique, documentation, new process for staff debriefing), and Incident Reporting. If available, all video footage of ESIs will be viewed.
  • 08.19.21 Revisit was conducted for all deficiencies cited on 07.08.21. All deficiencies have been corrected, and no new noncompliance was found. Facility in compliance with all regulations surveyed.
  • Survey Team Composition and Workload Report –
    • Surveyor 1 onsite 9.5 hours 8am – 6pm; 8.25 travel hours, 7.5 off-site report prep hours (06/29/21 – 06/30/21).
    • Surveyor 2 onsite 19.5 hours 8am – 6pm; 5.25 travel hours, 13.5 off-site report prep hours (07/06/21 – 07/08/21).
    • Surveyor 1 onsite 4.5 hours 8am – 6pm; 6 travel hours, 1 off-site report prep hours (08/19/21).
    • Surveyor 2 onsite 4.5 hours 8am – 6pm; 5.5 travel hours (08/19/21).

PRLU or OLTC

Visit Compliance Report

  • Specialist reviewed camera footage of incident; Staff member can be seen directing resident to his room when resident knocks over a water cooler. Staff member can then be seen forcibly shoving the resident into his room as she continues to charge into the room. There is no video footage of what occurred when she entered the room, but several staff immediately entered and removed the staff member from the area.
  • Specialist reviewed camera footage of a staff member entering the room, jumping into resident’s face. After the resident reacted by throwing his lunch tray, hitting the staff member in the face, the staff member grabs the resident and flings him around and forcibly on the ground. Other staff did not assist. After several minutes, the resident was let up and de-escalates speaking to other staff.
  • Regs not correctable –
    • R905.10 – Staff violated this standard when he placed resident in a restraint hold in effort to solely gain his compliance.
    • R905.9 – Staff did not use minimal force when conducting an improper restraint hold on resident.
    • R907.3 – Staff were out of ratio 1:7 prior to the incident per camera footage. A staff member was assigned to the room but left his post.
    • R905.4.g – Staff member was suspended, then terminated.
    • R109.1.g – Staff member acted unprofessionally and participated in behavior that can be
      seen as endangering and exploitative. Staff was terminated from employment on 7/5/21.