Perimeter Behavioral of the Ozarks / Woodridge of the Ozarks

On 5/17/23, resident was seen self-harming with contraband she retrieved from a pen that she stole from a staff member. Staff support was called. RN arrived and attempted to de-escalate and retrieve contraband, but resident became aggressive while trying to retrieve contraband. Resident was placed in a physical hold to maintain safety. Resident continued to escalate while in the restraint. Provider notified and gave an order for administration of an intramuscular (IM) medication to assist in regulation. Resident received IM medication and was able to transition out of physical hold when safe behaviors were exhibited. No injuries noted on resident from restraint, but a staff member was injured with the piece of the pen while transitioning into the physical hold. She obtained a small laceration on her thumb with minor bleeding. Facility policies and procedures currently in place. Resident placed on self-harm precautions with constant line of sight and placed in paper scrubs. Therapist to follow up for duration and individualization of safety plan.

Licensing narrative:

• 5/19/23 – Licensing emailed the facility to determine if this resident was already on a safety plan at the time she self-harmed.
• 5/30/2023 – Licensing Specialist followed-up with facility on if a safety plan was already in place.
• 5/31/2023 – Licensing Specialist informed that resident discharged on 5/31/2023.

On 5/17/23, resident was seen self-harming with an object she obtained on her forearm. Additional staff and RN called to assist. Staff/RN attempts to de-escalate were unsuccessful and resident became physically aggressive towards staff while trying to retrieve contraband. Resident was placed in a physical hold to maintain safety. When resident was able to show safe behavior and verbalize ability to maintain safe behaviors, resident was transitioned out of the physical hold. No injuries obtained. Resident placed on a self-harm precaution safety plan with constant line of sight. Therapist notified for follow up to determine duration and individualization of safety plan.

Licensing narrative:

• 6/7/2023 – Licensing Specialist inquired about the contraband that resident used to self-harm.
• 6/8/2023 – Licensing Specialist informed that resident attempted to self-harm with a piece of a paper cut.

On 5/16/23, resident became very dysregulated in the classroom and moved into the hallway. Once in the hallway, resident began picking at self-harm spots on her arms. Staff tried to stop the self-harming by blocking attempts and called the nurse for support. The nurse then showed up and attempted to redirect. Resident then attempted to hit her head on the wall with enough force to cause injury. Due to concerns for the resident’s safety, the nurse called for a physical hold and contacted the provider. I reviewed the current oral medication with the provider. After explaining the situation to the provider, the nurse returned to restraint. Resident appeared relaxed and calm. The restraint was ended. After the restraint, resident willingly received a one-time PRN medication to assist with continuation of emotional regulation, and this medication was well tolerated. She was compliant and seemed calm enough to rejoin the milieu. A physical assessment following the restraint found no injuries from this incident and only a minor exasperation of the existing superficial abrasion on residents’ forehead. The provider also made adjustments to resident’s current medication regimen for mood stability. Resident will be on a safety plan including constant line-of-sight monitoring for a period to be determined by the therapist.

On 5/15/23, resident was seen picking a spot on their face with their fingernails and smearing blood around. Resident was assessed by RN, superficial wound was cleaned and covered. No further incident occurred. Resident places on self-harm precaution safety plan with constant line of sight as a result. Therapist to determine duration and individualization of safety plan.

On 5/15/23, RN was called to blue unit where he observed the resident opening skin on left arm in attempts to cause damage by self-digging into skin with fingernails. Resident was noted to be aggressively yelling at peers and threatening staff during at this time. To maintain the safety of herself/others, and to remove from overstimulating stimuli, the resident was escorted off the unit to the comfort room. During the escort, the resident was fighting staff via kicking with intent to injure. To maintain the safety of the resident and staff, a physical hold was initiated. Resident was transitioned out of the hold when safe behaviors were exhibited and was given a PRN ordered medication per resident request. Resident continued to process 1:1 with staff in the comfort room until able to return to unit. No injuries occurred during restraint. Resident was placed on a self-harm and assault precaution safety plan with constant line of sight as a result of this event. Therapist to determine duration and individualization of safety plan.

Staff called nurse to unit and reported patient has been self- harming. Patient has been picking at previous wound on leg and making it bleed again. Patient initially non-communicative but after trying to process, nurse was able to get the patient to talk and quit picking at area. Patient stated that the unit had gotten too loud because of two other residents arguing. They were also able to be de-Escalated. Patient requested PRN medication, and it was given by nurse as ordered. Leg was also assessed, cleaned, and bandaged. Self-harm precautions in place, and therapist notified to discuss with patient if any other precautions are needed and the duration of it.

On 5/10/23, resident became upset and began hitting their head on the wall and scratching their skin with intent to injure themselves. Verbal de-Escalation and blocking techniques were unsuccessful, and resident had to be placed in a brief physical hold. Resident was transitioned out of hold when safety criteria was met. Superficial scratches noted on the skin, no nursing care required. Resident placed on a self-Harm precaution safety plan with constant line of sight, and will meet with therapist to determine duration/Individualization of safety plan.

On 5/10/23 at around 20:00 patient creates a superficial self-harm wound on her left forearm. Nurse cleaned the wound and bandages it. Patient reported she did it due to the unit being loud and her recent court appearance. Patient was placed on self-harm precautions. Therapist to consult with resident to determine if any other precautions are needed and to discuss length of them.

Licensing narrative: 5/11/2023- email sent to the facility requested further information including resident guardianship and the cause of the unit being “Loud”.

On 5/10/23 at 20:00, patient self-harmed by scratching self with a piece of plastic on forearms. Staff processed with patient. Contraband was retrieved by staff. RN cleaned wound and assessed patient. Placed on self-harm precautions. Therapist to consult with patient to see duration of precautions and if anymore are needed.

Licensing narrative:

• 5/11/2023 – Licensing emailed the facility to determine what the plastic was that the resident used to self-harm.
• 5/30/2023 – Licensing Specialist followed-up with facility on the plastic that the resident obtained.
• 6/7/2023 – Licensing Specialist inquired about the piece of plastic that resident self-harmed with.
• 6/8/2023 – Licensing Specialist informed it is unknown how the resident obtained the piece of plastic. It was reported that the piece of plastic was small in size.

Resident created a superficial self harm wound on her left forearm with her fingernails. Reported that she did it because the unit got too loud. Assessed, cleaned, and bandaged by RN. Resident placed on self-harm precautions. Therapist to consult with resident to determine if additional precautions are needed and the length of time they will stay in place.

On 5/9/23 it was reported to RN that resident had scratched their arms in response to residents yelling in the dayroom at one another and the unit being to noisy. RN assessed arm. Superficial scratched noted to the lower forearm. Scratches cleaned with soap and water. Resident placed on a self-harm precaution safety plan with constant line of sight. Therapist notified, resident to be seen by them the following day to discuss duration or individualization of safety plan.

Notified 4/26/23 at 6:09p RN was called to the unit and found resident self harming with what appeared to be cardboard from an ear plug package. Staff gave the RN a piece of a croc shoe charm (plastic/rubber) the resident used to make the original laceration. It was observed the wound was no longer bleeding but the cardboard was being rubbed vigorously in attempt to prolong the bleeding. RN and staff attempted to physically block resident and verbally de-escalate her with deep breathing exercises. When this was not successful, a staff with a great rapport with the resident came in attempts to de-escalate and was successful. The area on her left arm was opened and dried blood was present. Area was cleaned and bandaged. Self harm precautions were initiated by nursing for safety. The assigned clinical therapist will further assess to determine further self harm protocols.