Perimeter Behavioral of the Ozarks / Woodridge of the Ozarks

On 6/5/23 at 14:18 patient had to be restrained due to trying to self-harm and trying to assault staff. Nurse who was trying to process with patient was physically blocking the self-harm attempts when patient tried to kick her. Patient had been escalating for sometime, refusing all attempted interventions and redirections. Patient refused to process or let staff know what was wrong. Safety plans initiated. Patient to consult with therapist to see if any other interventions are needed and the duration of them. Licensing narrative: Licensing Specialist reviewed provider reported incident for licensing concerns. Licensing Specialist will inquire about how the resident tried to self-harm and safety plans initiated.

• 6/9/2023: Licensing Specialist informed that resident attempted to self-harm with her fingernails.

At about 18:19 nurse was walking to med room when staff called nurse to unit. Patient was self-harming by hitting herself in the face repeatedly. Patient would not stop and had to be restrained. During patient’s restraint, patient was calm but non-communicative. Patient was released from restraint at 18:30 by staff. Patient remained non-communicative and was taken off the unit by staff to process. Safety plan was initiated. Therapist to consult with patient to see if any additional precautions are needed and length of time.

Licensing narrative: Licensing Specialist will inquire about the initiated safety plan.

• 6/8/2023: Licensing Specialist informed that resident was placed on 1:1 supervision.

On 5/25/23 at approximately 1500, resident obtained a nail while outside and began to attempt to self-harm with it on her arm. Staff intervened immediately, and she willingly handed the nail over. Because the contraband was noticed and retrieved promptly by staff, no injuries were sustained from this attempt. Resident processed event with therapist and was placed on a self-harm precaution safety plan with constant line of sight.

Licensing narrative: Licensing Specialist reviewed provider reported incident. Licensing Specialist will follow-up with facility regarding this incident.

• 6/7/2023: Licensing Specialist inquired about a prevention plan when residents are outside.
• 6/8/2023: Licensing Specialist informed by Director of Nursing (DON) that resident was trying to self-harm from a nail. DON informed Licensing Specialist that repairs have been made to the building and that is probably where the resident got the nail from the grounds. Moving forward, DON and risk manager have developed a checklist for staff to follow when residents are scheduled for outdoor activities. Maintenance supervisor has ben advised to check buildings and grounds when contractors are brought in for repairs.
• 6/9/2023, Licensing Specialist requested a copy of the checklist that was developed. Licensing Specialist provided with outdoor visual inspection for the facility.

On 05/23/23 at approximately 23:30, it was reported that a resident placed a screw into her vagina. While doing so, she scratched the inside of her vagina, resulting in minor bleeding. RN arrived and assisted to the nurses’ station where area was assessed by 2 RNs. Minimal bleeding was noted at the time of assessment. The nursing staff was unable to visualize the entirety of the scratch that went up further in the vaginal canal. EMS was called for transport to the hospital for a more thorough assessment. Provider notified. Client was assisted out of the facility at 00:15 by EMS and floor staff. Client verbalized that the insertion of the screw was an attempt to hide/conceal the contraband. No significant injury requiring follow-up was noted in the discharge paperwork. Upon arrival back to the facility, client was placed on a 1:1 level of observation with hourly body searches, given paper scrubs to don, and placed in the comfort room.

Licensing narrative:

• 5/24/2023 – Licensing visited the facility and discussed this incident. It was still unknown where the resident got the screw from. The resident was seen in paper scrubs standing in the “Comfort room”. The resident had several injuries up and down her arms from what appeared to be fingernail marks in attempt to self-harm. Licensing also viewed the resident’s bedroom which was completely empty. The CEO reported that the resident’s mattress, bedding, and clothing were removed, as she is staying in the comfort room until she can become stable and rejoin the unit.
• 5/31/2023 – Licensing Specialist followed-up with facility regarding resident’s precautions. Licensing Specialist informed that resident had been discharged into an acute setting.
• 6/1/2023 – Licensing Specialist inquired if resident will be returning to the facility. Licensing Specialist informed that resident will not be returning to the facility.

On 5/20/23, RN called to the unit for additional support where resident was in the hallway picking at self-harm spots on her arms. Staff tried to stop the self-harming by blocking attempts and verbally de-escalating. Resident began to hit her head on the wall with enough force to cause injury and began kicking her legs at staff. Due to concerns for safety, the nurse called for a physical hold and contacted the provider. Resident was transitioned out of the hold when they appeared relaxed and calm and could verbalize ability to remain safe. Resident taken to nurses’ station where existing self-harm wounds were cleaned and covered. No injuries sustained from physical hold. Resident will be on a self-harm safety plan including constant line-of-sight monitoring for a period to be determined by the therapist.

5/19/23 at about 7:10 AM staff reported that resident had removed bandages and began to self-harm by picking her scabs until they started bleeding again. Resident was able to be verbally de-escalated but would not disclose why she was upset. She only stated to staff that she felt like she had done something wrong and was mad at herself. Area was cleaned and patient was instructed to return to nurse after her hygiene was complete so that the are could be rebandaged. Safety plan initiated. Therapist to consult with resident to determine if additional precautions are needed and the length of time they will remain.

On 5/17/23, resident became upset after a verbal disagreement with peer. Resident was taken to the comfort room, but continued to escalate and began banging her head on the wall and scratching her neck. Resident was placed in a brief physical hold for safety, and released once safe behaviors were exhibited. Self-inflicted superficial scratches were noted to resident’s neck (no first aid required). Resident was placed on a self-harm precaution safety plan with constant line of sight, and her therapist will determine duration and individualization of safety plan.

On 5/17/23, resident became dysregulated after a verbal disagreement with peer and began hitting her head on the wall and scratching her arms. 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.

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.