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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Police Report

Assault, Battery

Caller (staff) stated she would like to press charges due to her being assaulted by juvenile. Caller stated juvenile was being violent with a staff member and when she went to assist, juvenile grabbed a chunk of her hair and pulled it out. Police responded to scene.

PRLU or OLTC

Corrective Action Agreement

  • The following non-compliance areas have been cited during the past six months:
    • 103.8 Central Registry and Criminal Records Checks – Facility received citations on 12/14/21 regarding the staff Central Registry and Criminal Record Checks.
    • 103.11 Central Registry and Criminal Records Checks – Facility received a citation on 6/9/22 regarding staff allowing staff to work with prohibited charges.
    • 910.1 Grounds – Facility received citations on 6/3/22 regarding facility grounds.
    • 911.6 Buildings – Facility received citations during 6 visits regarding facility buildings.
    • 911.15.f Buildings – Facility received citation on 3/1/22 regarding facility buildings.
    • 912.4 Bathrooms – Facility received citations during 4 visits regarding the conditions of the residents’ bathrooms.
    • 907.2 Ratio and Supervision – Facility received citations during 2 visits regarding ratio and supervision concerns.
    • 907.3 Ratio and Supervision – Facility received citations during 2 visits regarding ratio and supervision concerns.

PRLU or OLTC

Notice of Incident

  • Maltreatment
    • Client reported to nursing staff that a staff member “crossed boundaries” with her when he grabbed and touched her butt. Facility staff reviewed camera footage which corroborated the allegation. Alleged staff member was sent home.
    • Child Abuse Hotline was called and accepted. Licensing follow-up: On 6/8/22, Licensing requested all documentation or correspondence regarding client’s regulatory checks. On 6/9/22, Licensing reviewed camera footage during an on-site visit. Camera review showed staff did act in an unprofessional manner when he engaged in behavior that can be viewed as sexual with a resident. Additionally, staff was given an ineligible to work status in March of 2022 by Licensing, but the facility allowed him to continue working directly and unsupervised with residents.

PRLU or OLTC

Visit Compliance Report

  • Licensing Specialist: Chelsea Vardell.
  • Facility visited from 12:30 – 15:15. One unit was closed due to the sprinkler flooding the unit. Licensing discussed the progress of the shower pans being replaced on the units. The maintenance staff reported that the second bid was placed on the installation of the shower pans today and that he must wait for a third bid to be placed. Once the third bid is placed, the building owner will pay to have the shower pans repaired. Licensing discussed ensuring that any showers with tile breakage not be used by residents until they can be repaired. Maintenance stated they will need an additional 30 days for repairs to be made as the original compliance date given for repairs was 6/8/22.
  • Regs out of compliance –
    • R907.3 – A unit was seen out of ratio (14:2). Staff reported only 2 staff were scheduled, but that they also have a floater that goes back and forth between 2 units. Licensing spoke with the CEO of the ratio concern and an additional staff was brought in from another unit. Due date and correction date: 6/3/22.
    • R910.1 – Dayrooms and bedrooms were seen with multiple snack and candy wrappers on the floor. The CEO stated the direct care staff are supposed to ensure that residents are cleaning their rooms each morning and afternoon. CEO reported he will follow up and ensure this is completed. Due date: 6/3/22.
    • R913.5 – Bed cover in room 301 had multiple blood stains. Staff working stated the resident had some kind of incident that morning. Licensing requested the bed cover be replaced with clean sheets and cover. Due date: 6/3/22.

PRLU or OLTC

Notice of Incident

  • Arrest (1)
    • Client was aggressive and assaulted an RN. Client then obtained a shank from another resident and used it to injure 2 RNs. Staff attempted to redirect and restrain client.
    • Licensing follow-up on 6/3/22: Visited facility and reviewed the camera footage of the incident.

PRLU or OLTC

Notice of Incident

  • Arrest (3)
    • Client was hitting staff and broke off a piece of the exit sign, then attempted to injure staff with the shank she was using from the exit sign. Staff restrained client, and client then put the shank in her mouth and spit it to a peer. Client was then placed in handcuffs and taken into custody.
    • Licensing follow-up on 6/3/22: Visited facility and reviewed the camera footage of the incident.

PRLU or OLTC

Notice of Incident

  • Arrest (2)
    • Client was defiant and not following directions after the fire alarm was set off by a peer. Client began punching police officers on scene. Client was arrested and taken to JDC. Staff attempted to intervene while client was attacking police officers but was hit by client.
    • Licensing follow-up on 6/3/22: Visited facility and reviewed the camera footage of the incident.

PRLU or OLTC

Notice of Incident

  • Arrest (4)
    • Client broke the door window on the blue unit, climbed onto furniture, and broke the sprinkler. The fire alarm went off and the resident attempted to elope from the facility after the doors unlocked. Staff stayed with the resident and attempted to redirect her outside the facility. The resident never left facility grounds.
    • Licensing follow-up on 6/3/22: Visited facility and reviewed the camera footage of the incident.

PRLU or OLTC

Notice of Incident

  • Arrest (5)
    • Client was aggressive with staff, attempting to break a window on the blue unit, then climbed on furniture to break the sprinkler. The fire alarm was set off and the resident attempted to elope, but staff maintained visual on her in the yard outside the facility. The client was aggressive towards staff and police, so she was arrested.
    • Licensing follow-up on 6/3/22: Visited facility and reviewed the camera footage of the incident.

PRLU or OLTC

Notice of Incident

  • ER Visit (Possible Seizure)
    • Staff reported they saw client in the hallway when she began shaking. Client’s eyes rolled back, and she fell onto the floor striking the back of her head. EMS was called and transported client to the ER. No follow-up details.

PRLU or OLTC

Notice of Incident

  • ER Visit (Self-inflicted Injury)
    • Client stated she inserted a piece of metal into her stitched wound on her hand. Staff then observed client insert another piece of metal quickly into the wound before staff could stop her. Client was taken to ER. No follow-up details.

PRLU or OLTC

Notice of Incident

  • ER Visit (Sprayed by Sprinkler)
    • Client was sprayed in the face by the sprinkler system after a peer broke the sprinkler, setting off the alarm. Client reported that when she was sprayed, she passed out onto the floor. Client was taken to ER. No follow-up details.

PRLU or OLTC

Notice of Incident

  • ER Visit (Self-inflicted Injury)
    • Client cut herself with a piece of glass while in the shower and shoved the glass into the open wound. Client was taken to ER.
    • Licensing follow-up on 6/2/22: Specialist emailed facility to determine how the client was able to obtain glass to self-harm with. Facility reported the client stated she found the glass in the “calm down room”, but there is no window and staff were unable to locate any glass. Client received 5 stitches to the wound. On 6/3/22, Licensing viewed the buildings and grounds, but was unable to locate any loose glass.

PRLU or OLTC

Notice of Incident

  • ER Visit (Self-inflicted Injury)
    • Client was found to have cut herself with a floor tile from the bathroom. The client opened previous wounds on her arms and extended the wound. Client was taken to ER.
    • Licensing follow-up on 5/27/22: Specialist emailed the facility regarding the progress of the bathroom tile repair, since the same client cut herself with a different tile 3 weeks prior. The facility reported 1 quote has already been received and they are waiting for 2 other quotes to be completed.

PRLU or OLTC

Notice of Incident

  • Arrest
    • Client attacked 3 staff members in a classroom, beating on the walls and throwing water jugs at staff. The police were called, and the client was taken into custody and placed with JDC. No follow-up details.

PRLU or OLTC

Visit Compliance Report

  • Licensing Specialist: Clayton DeBoer.
  • Facility visited from 10:30am – 12:00pm. Census: 32. MARs checked for multiple residents.
  • Regs out of compliance –
    • R912.4 – Paper trash sacks are being used as garbage receptacles in bathrooms. Some of these trash sacks had garbage overflowing. Due date and correction date: 5/10/22. Staff stated he is researching a garbage receptacle that cannot be used to self-harm.
    • R911.6 – Shower basins have pulled up tiles (tiles approx. 2×2 inches) that have been filled with concrete. Shower tiles around the drain are cut in a way that they could be used to cut or cause harm to clients. Due date: 6/10/22. Staff stated he is researching having the shower basins replaced.

PRLU or OLTC

Notice of Incident

  • Suicidal
    • Client was found in bathroom with broken tile and large gash to left forearm. The tile was removed, and first aid administered. Client was sent to ER and received 7 stitches to her arm. Safety plan in place. Client on constant Suicide Risk for 7 days.
    • Licensing follow-up on 5/10/22: Facility visited, and shower basin observed. The tiles surrounding the drain have been removed and filled with concrete. The tiles surrounding the drains of all the showers observed today but one, are cut in such a way that they could be used for self-harm. Staff stated he is researching having the shower basins replaced.

PRLU or OLTC

Notice of Incident

  • ER Visit (Sputum Blood)
    • Client was coughing for 2 days when staff noted blood in her sputum and no improvement of symptoms. Client was taken to ER. No follow-up details.

Police Report

Disturbance

Caller advised juvenile was destroying property and roaming the building looking for a sharp object. Officers arrived on scene and juvenile had calmed down.

PRLU or OLTC

Visit Compliance Report

  • Licensing Specialist: Chelsea Vardell.
  • Census: 31. Specialist conducted facility visit from 1240 – 1525. MARs reviewed for 3 residents. Residents on the blue unit mentioned concerns about rats, spiders, mold, and lack of hot water. Residents also complained of a staff member who they reported makes them feel uncomfortable. One resident reported “[staff member] always stares at our butts.” Residents reported they do file grievances, but no one ever comes and talks to them about it. Licensing spoke to staff about residents’ concerns: Concerns about pest control are being addressed by the pest control company that visits the facility a minimum of 2x/month. Concerns of mold were checked, and one room was found to have mold in the shower. Concerns of staff and grievances were discussed, and staff stated he receives the grievances and will follow up with the residents. Specialist discussed with staff how to ensure residents have access to file concerns.
  • Regs out of compliance –
    • R911.6 – Outlet cover was broken off in the hallway of the blue unit. Mold was visible in the ceiling of the shower in room 303. Due date 4/15/22.
  • Regs not correctable –
    • R907.3 – Ratio on blue unit was 10 residents to 1 staff. Staff reported that no other staff was scheduled to the unit and only 1 staff is “always” assigned to the unit. Ratio on green unit was 9 residents to 1 staff. Staff reported that no other staff was scheduled to the unit and due to the facility being short staff there has been only 1 staff assigned to the unit in recent weeks.
    • R908.8 – MARs for client had medication documented as administered at 16:00 even though it is currently 14:10.

PRLU or OLTC

Revisit Survey, Validation Survey with POC

  • A validation survey was conducted 4/4/22 to 4/7/22.
  • Regs out of compliance –
    • N 131 – Facility failed to ensure chemical restraint and seclusion were not used simultaneously for 1 resident.
    • N 143 – Facility failed to ensure a physicians order for a physical restraint was signed by the physician for 1 resident.
    • N 207 – Facility failed to ensure serious occurrences were reported to the Office of Long Term Care and Disability Rights Arkansas were notified after suicidal attempts taken by 2 residents.
  • Plan of Correction – Retraining on restraints/seclusion, review of policies, operational rule for review of all ESIs, review of serious occurrence incidents for compliance with reporting with goal of 100% compliance monthly for 4 months.
  • A revisit was conducted on 5/9/22 for all deficiencies cited on 4/7/22. All deficiencies have been corrected, and no new noncompliance was found.

Police Report

Hang Up

911 open line from landline, in the background could hear someone yelling “help” a few times and then phone disconnected. No answer on call back. Officer arrived on scene; Juveniles had got a hold of the telephone, no emergency here.

PRLU or OLTC

Children's Records Review, Visit Compliance Report

  • Licensing Specialist: Chelsea Vardell.
  • Specialist conducted facility visit from 1220 – 1515. Facility CEO reported that repairs to the facility are proceeding, and the floors are being resurfaced today. Specialist completed record review for 5 clients.
  • Regs out of compliance –
    • R902.13 – Three clients missing immunization record, birth certificate & social security card. Two clients missing birth certificate & immunization record. Due date: 4/29/22.
  • TA –
    • R902.10 – Specialist provided education to staff on what information is required at the time of admission.
    • R902.12 – Specialist provided education to staff on what intake information should be gathered within ten days of admission.
  • Regs not correctable –
    • R903.4 – Client did not have a Master Treatment Plan in her chart. Client has been admitted for more than 30 days.
    • R905.17 – Restraint justification packet for client that was conducted on 11/20/21 would not be located.

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.