Disability Rights Arkansas

Perimeter Behavioral of the Ozarks / Woodridge of the Ozarks

Location: Springdale, AR

Population Served: Adolescent girls ages 7-17

# of residents per unit: Up to 12 Residents per room: 2 Capacity: 32

Contact with family (Calls and visit schedule): Weekly calls up to 3x/week for 10 minutes, intervention call available 1x/week for 10 minutes. Visitation available 2x/week for 30 minutes if previously scheduled. Zoom available if in person is not possible.

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

Treatment Components:

Clinical Director - LCSW

Therapists: 2 full-time therapists (1 LMSW, 1 LAC)

Treatment modalities offered: Facility declined to identify any specific modalities available.

# of individual therapy sessions/week: 1

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

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PRLU or OLTC

Notice of Incident

  • Elopement
    • Client began to wake up peers and was able to set off a fire alarm in room 302 causing the magnetic locks to disengage and doors on the unit to open. Client then eloped from facility out the main unit door, and 2 peers eloped off green and orange units. Law enforcement was contacted to assist in finding the 3 residents.
    • On 3/25, Specialist discussed the incident with the facility and staff reported they will be discharging client who has encouraged elopements by residents at the facility.

PRLU or OLTC

Notice of Incident

  • ER Visit (Strep Symptoms)
    • Client taken to ER after exhibiting strep-like symptoms.
    • Follow-up pending; Facility will follow-up with further information after discharge.

PRLU or OLTC

Notice of Incident

  • ER Visit (Vomiting)
    • Client taken to ER due to vomiting multiple times. Client could not hold any fluids or medications down.
    • Specialist was at the facility on 3/23 for licensing visit and was notified of the incident by the Director of Nursing. Specialist did not receive detailed incident report until 3/26.

PRLU or OLTC

Visit Compliance Report

  • A visit was conducted to check facility issues that were discussed the week before. All halls were cleaner than before, and no issues were found with toilets. Overall, the rooms and facility were in much better shape than last time.
  • Regs out of compliance –
    • R912.4 – Room 103 bathroom had some trash on the floor. (Due Date: 3/17/22)
    • R911.6 – Blue Hall had a dirty pile of towels on the floor walkway when walking in. A laundry bag was next to the pile. It was discussed that staff should be making sure clients put towels in bag (Due Date 3/17/22). Outlet on wall of hall was missing a cover (replaced on the spot).

PRLU or OLTC

Notice of Incident

  • Acute Care Placement
    • Client was placed in acute care after becoming upset during an attempted elopement on 3/12/22.
    • Specialist followed up on 3/15 regarding the elopement: Staff informed specialist they were attempting to placement for client.

PRLU or OLTC

Notice of Incident

  • Attempted Elopement
    • Client set off the fire alarm in her restroom to disable the locked doors on the unit. Client, along with peer on the orange unit, ran out the exit doors to elope.
    • Staff pursued the residents and were able to reach them while still on facility grounds. Clients returned to the facility willingly. Specialist followed up on 3/15 to determine if client was ever placed in acute care.

PRLU or OLTC

Notice of Incident

  • ER Visit (Ingested Plastic)
    • Client taken to ER after reporting she had swallowed 7 pieces of plastic and placed 4 pieces of plastic in her vagina. No follow-up details.

PRLU or OLTC

Visit Compliance Report

  • Buildings and grounds walkthrough conducted. The agency reported they have now hired a full-time housekeeper who is currently in orientation. Facility reported they will ensure the issues found are repaired immediately themselves instead of waiting for the owner of the building to repair them.
  • Regs out of compliance –
    • R912.4 – Restrooms were seen in poor condition with toilet paper on the floor, a used tampon on the back of the toilet, and hair all over the sinks. The toilet in Room 105 was clogged. Visible mold seen in the bottom of the shower in room 305. (Due Date: 3/9/22)
    • R911.6 – Dayroom and bedrooms in blue unit were messy with debris and used food wrappers on the floor. Dayroom and bedrooms on orange unit also in disarray. Amazon boxes seen in several rooms, and staff stated they were used by the girls for personal storage or as a trash can for their rooms. Profanity seen on the ceiling of bedroom (derogatory remarks about facility). The green unit had baseboard trim peeling from the wall in the dayroom. Water damage from a previous roof leak on the ceiling of the dayroom is currently being covered by a board (staff reported there is an order to fix the drywall). A shower still had several missing tiles (staff reported the tile replacement is the responsibility of the owner of the building they lease from; There has been an order to fix this for almost 1 year now without repair). The dining room area had baseboard trim falling off the wall (wall behind trim is rotted). (Due Date: 3/9/22)

PRLU or OLTC

Notice of Incident

  • Elopement
    • Five residents eloped from facility after client used a broom to set off the fire alarm by hitting the sprinkler in her room. Local police were notified to assist.
    • Specialist was made aware of the incident while conducting a building and grounds visit at facility on 3/8/22. Specialist discussed ensuring that reports are made to the Licensing Unit by the next business day.

PRLU or OLTC

Notice of Incident

  • ER Visit (Accidental Injury)
    • Client taken to ER after sustaining an injury to her knee while attempting to elope from the facility.
    • Specialist discussed the event with staff on 3/8/22.

PRLU or OLTC

Notice of Incident

  • ER Visit (Seizure)
    • Client taken to ER after having a seizure while attempting to elope from the facility.
    • Specialist discussed the event with staff on 3/8/22.

PRLU or OLTC

Notice of Incident

  • Complaint
    • Specialist was approached by 3 residents during a licensing visit who reported a feeling of being unsafe at the facility. Residents reported that 2 staff members and un unknown staff member have made comments about them in front of other residents to include that they don’t want to work with them or be around them.
    • The facility reported that they discussed the concerns with the staff and provided re-education to the staff. Due to there being no evidence to substantiate the claims made against staff, the Licensing complaint is unfounded.

PRLU or OLTC

Visit Compliance Report

  • Buildings and grounds walkthrough conducted.
  • Regs out of compliance –
    • R911.15.f – A ripped up clothing item was found in a bedroom that had been cut, giving it a long strip that could be used as a ligature. Staff removed the threat from the room immediately.
    • R912.4 – Several restrooms in the unit bedrooms were seen in poor condition. Restrooms had hair in the sinks, discarded toilet paper on the floors and on the back of toilets. Two toilets (Rooms 204 & 301) had feces sitting in them, clogged, and inoperable. Room 301 toilet was overflowing onto the floor. Room 303 toilet had a small leak around the base with standing water. (Correction Date: 3/1/22)
    • R911.6 – Several bedrooms were in disarray. Rooms had clothing on the floor, drink containers, and multiple empty food wrappers. Staff reported the rooms are supposed to be cleaned every morning by residents and staff are supposed to ensure they are clean prior to breakfast. Staff stated they do not believe room checks were conducted for the day. Additionally, the facility reports the agency is in the process of hiring a full-time housekeeper. (Correction Date: 3/1/22)

PRLU or OLTC

Notice of Incident

  • ER Visit (Accidental Injury)
    • Client slipped in the shower, injuring her right wrist. Client taken to ER. No follow-up details.

PRLU or OLTC

Notice of Incident

  • ER Visit (Peer Altercation)
    • Client was in altercation with 3 other residents. Client was taken to ER.
    • Specialist visited facility on 3/1 and reviewed camera footage. The camera shows 3 residents assaulting client on the ground, but the 2 staff failed to provide the level of supervision and care necessary to ensure the safety of the client. Staff 1 resigned her position on 3/1 and Staff 2 was retrained on appropriate procedures to handle a resident altercation on 2/28 before she returned to work on the unit.

PRLU or OLTC

Notice of Incident

  • ER Visit (Abdominal Pain)
    • Client reported abdominal pain and constipation on 1/18. Laxatives were ordered to be given throughout the day with no success. The client reported continued pain on 1/19 so the client was taken to ER. No follow-up details.

PRLU or OLTC

Personnel Record Review, Visit Compliance Report

  • Specialist completed 8 personnel record reviews.
  • Regs out of compliance –
    • R105.15.c – Staff member (1) does not have verification of his qualifications in his file.
    • R105.5 – Staff member (1) does not have verification of CPR/First Aid training.
    • R105.4.c – Staff members (2) have no documentation in their charts that they have been trained on the agency’s fire and disaster plans.
    • R105.15.h – Staff member (1) only had 1 of her 3 needed personal references.
    • R105.4.a – Staff member (1) does not have verification of training on confidentiality in her chart.
  • TA –
    • R105.10 – Please ensure that training documentation for personnel records dictates what trainings are “psychiatric specific” as standard R105.10 states each child caring staff should complete ten hours of psychiatric specific training before being counted in the child/staff ratio.
  • Regs not correctable –
    • R103.8 – Seven staff members did not have their initial background checks initiated within 10 days of their hire.

PRLU or OLTC

Notice of Incident

  • Complaint
    • Licensing Specialist received a complaint called in from a client’s guardian, alleging they believe there are pictures of the child on social media accounts, the facility gave client antibiotics without guardian’s consent, and the client had what the facility reported as “spider bites” all over her (guardian believes to be staph infection).
    • Specialist attempted to call the individual who provided the information, but no call was returned. Specialist conducted a visit to facility on 12/20 to review client’s chart, which stated client complained of a single sore on her stomach. The physician was notified and reported it to be a suspected spider bite. Client was prescribed antibiotics and consent was given via telephone by client’s father. Due to no proof of the social media photo, the agency will complete re-training of the social media confidentiality policy with all staff to ensure compliance.

Medicaid Inspection of Care

On-Site Inspection

  • Included: CAP
  • Multiple deficiencies noted.

PRLU or OLTC

Visit Compliance Report

  • Regs out of compliance –
    • R912.4 – Trash in bathrooms, dirty floors and sinks. Please ensure shower curtains are hung up and each bathroom has a trash receptacle that is emptied daily.
    • R911.6 – Several bedrooms had excessive amounts of trash. No trash receptacles in bedrooms.
    • R913.5 – Please ensure all beds have sheets.

PRLU or OLTC

Notice of Incident

  • ER Visit – Intestinal Blockage
    • Resident was experiencing stomach pain for a few days when it suddenly increased on the night of 9/21/21. Client was taken to ER for further evaluation.
    • Follow-up 9/22/21: Resident is still currently in the hospital and will be kept overnight again tonight to continue monitor her condition which has been identified as an intestinal blockage.

Police Report

911 Hang Up

911 Hang up from landline; Immediate disconnect. No voices heard. On callback there is no answer at the nurses station. Accidental.

Police Report

Physical Fight in Progress

Caller reported riot was taking place and they do not have the staff to calm everyone down (7 staff members); Fighting at Nurses Station and in the unit. Caller reported there are 2 adults trying to restrain Juvenile. Unknown why they are fighting.

PRLU or OLTC

Notice of Incident

  • Arrest
    • Resident was acting out trying to hit other residents and staff, pulled down one of the lights on the unit breaking the bulbs from it, and destroyed the door on the fire extinguisher cover. The decision was made to contact the police for further assistance.
    • Specialist emailed CEO to determine additional details and staff interventions before police were called. Specialist discussed in emails with CEO details regarding the resident’s discharge and if she was arrested. No video footage of the incident was available.

Police Report

Assault

Caller reported that Juvenile assaulted 3 employees and spit in their faces. No injuries.