- ER Visit
- Resident was in altercation with peer when he fell to the ground and injured his knee. Resident was taken to ER. No follow-up details.
PRLU or OLTC
Notice of Incident
PRLU or OLTC
Notice of Incident
- Complaint
- Resident reported that there are riots at the facility, the magnetic doors and hinges are busted on the doors so residents come onto his hall and elope, the police are called 3-4 times a week and recently a resident eloped for a week and a half before returning to the facility.
- Specialist requested incident tracking log and update to the repairs/replacement status of the magnetic door locks. The log received was incomplete and not well organized. The facility just hired a new Quality Care Coordinator who is trying to restructure the facilities reporting logs.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Resident reported to nurse that while transitioning this morning he was tired and laid down in the hallway floor, and staff came over and kicked him in the stomach/chest area.
- Staff member was placed on administrative leave as of 9/21/21 pending investigation. Child Abuse Hotline was called and accepted, unsubstantiated. Specialist visited facility to discuss incident. There is no camera footage where the incident took place, no witnesses, and the resident has no injuries. Resident claims the event took place while staff denies it. No further details.
PRLU or OLTC
Visit Compliance Report
- Reviewed buildings and grounds for PRTF and SRU programs. Records reviewed.
- Regs out of compliance –
- R1013.10 – Bed placement in 1 room (SRP) is not in a way that would prevent physical contact.
- R911.15.b – Found wire that could choke or be used for self-harm (was removed during inspection).
- R1011.7 – In 1 room (SRP), door wood is coming apart and should be fixed (safety concern); Floor tiles in seclusion room are coming up.
- R910.1 – Baseboard and trim fell off wall by closet in 1 room and nails were sticking out; Wire going up electrical pole outside was fraying and needs to be fixed by utility company.
- Viewed video of incident: AO seen choking and touching AV, to the point where AV appears to go limp. At one part of the video, AO is right out of camera view, but witness stated that the child was masturbating over AV. Witness was seen throughout the video being “watch out.”
- Regs out of compliance –
- R1007.2 – Proper supervision was not seen on video during time of incident and logs in children’s files indicated that supervision was done. Staff will be retrained on proper supervision and training participation log sent to program specialist.
PRLU or OLTC
Notice of Incident
- Elopement, ER Visit, Acute Care
- Resident eloped from facility by kicking open door at 6:30pm on 9/19/21. Resident did not return to facility until about 9:30am on 9/20/21. The resident complained of pain in several areas and the nurse noted several external wounds. Resident was taken to ER, then discharged from ER to an acute care facility.
- Agency contacted police department (at 6:39pm) after resident eloped. Program Manager & Coordinator visited facility on 9/20/21 and followed up with staff regarding incident.
PRLU or OLTC
Notice of Incident
- ER Visit
- Resident complained of ear pain/popping sounds. Nurse observed ear to be pink inside. It was determined that the resident had shoved tissue in his ears and the nurse was unable to retrieve it, so the decision was made to take him to the ER for removal of the tissue.
- Program Manager & Coordinator visited facility to discuss incident with staff.
PRLU or OLTC
Notice of Incident
- Sexual Abuse
- Resident disclosed to staff that peer had sexually abused him the night of 9/13/21 while another peer was the “lookout”.
- Peer was placed in a single room and transitioned to a different group and dayroom. During transition times throughout the day peer will be in front of the line. Changes were also made to the seating for dining and classroom. Child Abuse Hotline was called and accepted, outcome pending.
- Resident is currently on track to successfully complete the program and discharge on 9/17/21. Program Manager & Coordinator visited the facility in person and reviewed video footage, resident charts, and the bed check log conducted by the agency. It was determined that staff were falsifying bed check logs and not providing the level of supervision and care necessary to ensure the safety of the residents.
PRLU or OLTC
Notice of Incident
- AWOL
- Client went AWOL from facility from 2:27pm – 2:35pm and again at 3:25pm – 3:30pm. During the first incident, client burst through the lobby door of the admin building and went out of the lobby front door. During the second incident, the client burst through the doors by the dining hall and the lobby front door.
- Client was placed on AWOL precautions. Staff reported to Specialist that the facility is actively working with a company in effort to install stronger magnetic locks on the doors at the facility to ensure better security.
PRLU or OLTC
Visit Compliance Report
- Specialist discussed the Corrective Action Plan progress with staff; Facility has received 22 new beds and plan to order another 22. Facility has removed carpet in the gym and will replace it with new carpet. The building is currently being painted, and the facility is gathering new estimates for new flooring in children’s areas. New cameras have been installed, but the new system will need to be merged with the current system. Facility has received new cafeteria tables.
- Specialist discussed incident involving resident and staff and reviewed documentation; No camera footage of incident available. Licensing Complaint unfounded. Regarding another incident, specialist discussed ensuring all staff monitoring phone calls or on the floor who suspected child maltreatment report suspicions to the child abuse hotline.
PRLU or OLTC
Notice of Incident
- ER Visit
- On 9/1/21, a peer was moving a chair and accidentally hit a resident in the nose. The nurse assessed, and a cut was noted on the bridge of his nose. Resident complained of pain again on 9/2/21 in which it was decided to take him to the ER for further evaluation. No follow-up details.
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.