- 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
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.
PRLU or OLTC
Notice of Incident
- Maltreatment – Wrist Injury
- Resident reports he was threatened, then placed in a restraint hold by staff member after not complying to go inside the building. Resident sustained an injury to his wrist during the restraint and had to be taken to the ER for further evaluation.
- Staff member was placed on suspension on 7/6/21. Child Abuse Hotline was called and accepted.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Staff reported to nurse that resident was masturbating under the covers, so she recorded the alleged event on her cellphone.
- Facility suspended staff until investigation is completed. Child Abuse Hotline was called, not accepted.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Resident was placed in a restraint hold by staff member. Resident reports he was slammed to the floor by staff member.
- Resident was assessed for injuries by staff nurse and staff member was placed on suspension pending the results of the investigation. Child Abuse Hotline was called and accepted.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Nursing staff reported an incident that resident was in a physical altercation with a staff member. Resident reported that staff member shoved him, hit him in the mouth, and tried to choke him around the neck.
- Resident was assessed by nurse who noted no injuries, resident reported no pain. At the time of the incident, the staff member was asked to leave the room and she is now on suspension pending investigation. Child Abuse Hotline was called and accepted; Unsubstantiated.
PRLU or OLTC
Notice of Incident
- ER Visit – Consumed Toothpaste, Mouthwash, Hand Sanitizer
- Resident reported to the staff nurse that he drank a mixture of toothpaste, mouthwash, and hand sanitizer that he received from another resident. Resident complained of “burning of his side”. Resident was taken to ER for further evaluation.
PRLU or OLTC
Notice of Incident
- ER Visit – Self-inflicted
- Resident reported pain in his right hand after punching a wall. Staff nurse assessed the wound and noted swelling with the area reportedly tender to touch. Resident was taken to ER for further evaluation.
PRLU or OLTC
Notice of Incident
- ER Visit – Accidental Injury
- Resident was taken to ER after he injured his left pinky finger while playing basketball.
PRLU or OLTC
Notice of Incident
- ER Visit – Peer Altercation
- Resident was in physical altercation with peer when his right hand was stepped on. Swelling noted in fourth right knuckle. Resident taken to ER for further evaluation.
PRLU or OLTC
Notice of Incident
- ER Visit – Abdominal Pain
- Resident was taken to ER after complaining of severe abdominal pain.
PRLU or OLTC
Notice of Incident
- ER Visit – Ankle Pain
- Resident complained to nurse of left ankle pain. Nurse assessed and noted swelling, so resident was taken to ER for x-rays.
PRLU or OLTC
Notice of Incident
- ER Visit – Rib Pain
- Resident was taken to ER after complaining of right rib pain.
PRLU or OLTC
Visit Compliance Report
- Reviewed camera footage for 2 incidents; Reviewed training and corrective actions in the personnel files for 3 staff. Specialist discussed documenting complaints made against staff and corrective actions in their individual files, as well as staff needing re-training on behavior management.
- TA –
- R911.10 – Discussed repairs being made to A/C units and busted water pipe in 100 hall. Facility is in the process of getting estimates and moving forward with repairs. “Swamp Coolers” were placed in the affected areas of the building to provide air conditioning. Licensing requested that temperature be taken and documented in all areas where children are located; If the temperature reaches above 85 degrees, then children should be relocated to another area.
- Regs not correctable –
- R905.4.g – Staff used improper physical force on resident in effort to gain his compliance. Facility reports staff member was suspended for 3 days and allowed to return to work where she was retrained and coached on handling an ESI properly.
PRLU or OLTC
Notice of Incident
- ER Visit – Peer Altercation
- Resident was in a physical altercation with peer. Resident sustained a laceration to his lip during the altercation. Resident was taken to ER for further evaluation.
PRLU or OLTC
Notice of Incident
- ER Visit – Consumed Rubbing Alcohol
- Resident reported to nursing staff that peer had drank rubbing alcohol with him and was now acting weird. Resident was evaluated by nursing staff and seen to be tachycardiac and diaphoretic. Resident was taken to ER for further evaluation.
- Child Abuse Hotline was called, not accepted
PRLU or OLTC
Visit Compliance Report
- Regs out of compliance –
- R911.15.f – Strings in sweatpants were noted in a resident’s room. Staff took sweatpants to nurses’ station so strings could be removed.
- TA –
- R911.10 – A/C units were randomly out of service around the facility; A/C units have not been working for about a week. Staff stated that an order is in to fix system, and portable air conditions along with fans have been brough into facility to cool the rooms. Water was noted in the 100-hall running into the hallway, noted water damage along hall wall; Specialist had staff put caution sign in the hall to warn others and requested maintenance clean up the water as soon as possible. Facility will have the leak assessed.
- R913.5 – Several rooms noted to have no bed sheets or pillowcases. Residents of those rooms confirmed that they had denied the sheets and prefer to sleep without sheets.
PRLU or OLTC
Notice of Incident
- Maltreatment
- Resident reported to nurse he was slammed to the floor by staff. Camera footage was reviewed and showed staff member placing the resident in a restraint hold incorrectly.
- Staff member was terminated from employment. Child Abuse Hotline was called and accepted.
PRLU or OLTC
Notice of Incident
- ER Visit – Peer Altercation
- Resident complained to nurse of pain in his hand that began after an altercation wit another resident. Resident was taken to ER for further evaluation of his hand.
PRLU or OLTC
Notice of Incident
- ER Visit
- Resident was taken to ER for examination of his right hand after he punched a wall.
PRLU or OLTC
Notice of Incident
- ER Visit – Consumed Rubbing Alcohol
- Resident was acting “strange”, so he was sent to the nurse. It was discovered that resident potentially drank rubbing alcohol and was immediately transferred to ER for further evaluation.
- Child Abuse Hotline was called, not accepted.