Another hang up from Ozark Guidance. No signs of emergency.
Police Report
Hang Up
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 1
- Client was triggered by a peer and began using her fingernail to reopen superficial abrasions that caused minimal bleeding. Nurse cleaned abrasions and processed with client. Client will continue self-harm precautions with constant LOS.
- Licensing follow-up: Licensing visited facility and observed client within LOS of staff in classroom. Classroom was in ratio.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 2
- Client became dysregulated and began hitting themselves in the face. Client was placed in a physical hold after de-escalation attempts were unsuccessful. Once safe behaviors were exhibited, client was released and minimal dry blood on client’s face was cleaned. Client processed with staff and self-harm precautions with constant LOS was initiated.
- Licensing follow-up: Unannounced licensing visit conducted. Facility was in ratio and no supervision concerns were observed. Client is currently on safety plan and therapist continues to monitor client.
PRLU or OLTC
Complaint, Notice of Incident, Visit Compliance Report
On 3/10/23 the current CEO of the facility had participated, in part, of a restraint hold with a resident although she does not have the proper training and/or certification to do so. The reporter stated that the CEO was using her hand to shield a resident that was in a restraint hold from headbutting staff. The reporter states that the CEO was asked multiple times to allow another staff to assist as she does not have her restraint training. The CEO reportedly refused. The reporter also mentioned concerns about the CEOs comments about the residents. The reporter states that the CEO said, in front of approximately six staff, that she would “love to put her in paper scrubs to humiliate her”. Licensing Specialist: Rachel Carlton.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 1
- Client was placed in a physical hold after she began scratching herself and attempting to hit her head on the wall. Client was able to regulate emotions and process with staff. Nurse cleaned superficial scratches (minimal bleeding) on client’s forearms, and client was placed on self-harm precautions x7 days with constant LOS.
- Licensing follow-up: Unannounced licensing visit conducted. Client’s current safety precautions were observed at time of visit, and therapist continues to monitor client.
PRLU or OLTC
Notice of Incident, Self-Injury, Visit Compliance Report
- Self-inflicted Injury 2
- Nurse was called to assist due to client standing in a chair with glass in hand from the ceiling lightbulb, and ceiling tiles hanging above her. A physical hold was initiated to retrieve the glass from client, and client also released an object from her mouth. Due to extreme self-injurious behaviors, a one-time IM emergency medication was administered to help de-escalate client. Nurse cleaned 2 new ½-inch superficial cuts on client’s hand. Client will remain on 1:1 observation.
- Licensing follow-up: Facility visited on 03/15/23 and camera footage reviewed (view was limited due to a resident breaking a camera). The facility was in ratio at time of incident, and no supervision failures were observed. Client was observed wearing paper scrubs and programming 1:1 with staff in the comfort room during visit. Facility has made referrals to acute care.
Police Report
Hang Up
911 hang up, no sounds of distress. Upon call back, staff stated there was no emergency.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury
- Client became escalated and began picking on her arms. Client responded to verbal de-escalation after some time, and nurse noted a reopened scab on her wrist and arm with minimal bleeding (area cleaned). Client will remain on 1:1 observation and 1:1 LOS.
- Licensing follow-up: Unannounced licensing visit conducted. DCFS given notice regarding client due to acuity of her behaviors. Client is currently off 1:1 supervision but is restricted to her unit with several peers; Client was observed within LOS of staff.
PRLU or OLTC
Notice of Incident, Suicide Attempt
- Suicide Attempt
- Client pulled the extension cord through the plexiglass around the TV and wrapped it around her hands. After staff removed the cords, client re-escalated and attempted to tie a shirt around her neck. Client was placed in a physical restraint, during which she scratched multiple staff members. Once calm, client was released and no injuries were noted. Client will continue assault and property destruction precautions x7 days and was placed on self-harm precautions with constant LOS x7 days.
- Licensing follow-up: ADON and CEO reported client pulled the extension cord that is secured behind the TV box. Staff are being trained on “imminent risk” to make better decisions about when restraints are appropriate to ensure residents are prevented from self-harming.
PRLU or OLTC
Monitor Visit, Visit Compliance Report
- Licensing Specialist: Michele Sutton.
- Facility in ratio at time of visit. Follow-up on self-reports received prior to visit: 1:1s were being observed per constant LOS self-harm precautions. Facility has started filling gaps between the anti-ligature box and toilets in the bathroom (cited previous week) and will have completed by 03/15/23. Licensing viewed bathrooms and bedrooms with no concerns noted. Staff were interacting calmly with residents and no supervision/safety concerns were noted.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury
- In relation to escalated noise on the unit, client used her nails to open old scabs and create a new laceration on her arm. Superficial scratches were cleaned and covered. Client was placed on self-harm precautions with constant LOS x7 days.
- Licensing follow-up: Unannounced licensing visit conducted. Client’s safety plan ended on 03/13/23.
PRLU or OLTC
Notice of Incident, Peer Altercation, Suicide Attempt
- Suicide Attempt, Peer Altercation
- Client became agitated related to not feeling well and attempted to use her shirt as a ligature but was intercepted by staff. Client was placed in a physical hold after multiple attempts by staff to block her from self-harming. Client was able to self-regulate, and no injuries were noted. Approximately 1 hour later, client was involved in an altercation with peers and sustained superficial scratch marks on the side of her neck. The scratches were cleaned, and client was taken to the comfort room. Client was placed in another physical hold after attempting to tie paper scrubs around her neck. Once calm, client was released. Client was placed on assault precautions x7 days and suicide precautions with constant LOS.
- Licensing follow-up: Unannounced licensing visit conducted. Client was restricted to unit within LOS of 2 staff and wearing paper scrubs.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 1
- Client became defiant, argumentative with staff, and began kicking doors. Nurse was able to de-escalate client and cleaned superficial scratches to client’s forearm from self-harming. Client was placed on self-harm precautions with constant LOS until seen by therapist.
- Licensing follow-up: Unannounced licensing visit conducted. No additional incidents were reported since this incident, and facility was in ratio at time of visit with no supervision concerns noted.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 2
- During med pass, nurse noted scabs on client’s arm had been picked open. Client stated she managed to open some of them with contraband before it was taken by dayshift staff. Nurse cleaned wounds and client was placed on 1:1 observation and will continue 1:1 LOS.
- Licensing follow-up: Unannounced licensing visit conducted. Client is off 1:1 precaution but it restricted to the unit within LOS of staff. Notice given to DCFS due to acuity of client’s behaviors.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 3
- Client reported she had hidden and used her nail to create a small wound on her arm. Superficial wound was cleaned and covered. Client was placed on self-harm precautions x7 days with constant LOS.
- Licensing follow-up: Unannounced licensing visit conducted. Client’s self-harm precautions expired.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury
- Client escalated and began punching walls, trying to pull sockets out of the wall, and continuing to pick open her scabs. Client was given an IM medication, and client was able to calm down in the comfort room with staff assistance. Nurse assessed and treated minor opened scabs (minimal bleeding). Client will continue 1:1 LOS.
- Licensing follow-up: Licensing observed client programming 1:1 with staff during facility visit. Facility has made multiple acute care referrals.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury
- Client approached nursing staff with scratches on both forearms. No staff witnessed the self-harm event. Nurse cleaned client’s arms and covered the scratches after client’s shower. Observation level modified from Q15 to LOS constant. Client will process with her therapist.
- Licensing follow-up: Licensing observed client within LOS of staff during facility visit and verified current safety precautions.
PRLU or OLTC
Monitor Visit, Self Report Visit, Visit Compliance Report
- Licensing Specialist: Michele Sutton.
- Unannounced licensing visit completed. Licensing verified safety plan precautions were documented and observed for multiple residents, reviewed staffing sheet documentation, spoke to CEO regarding resident, and observed comfort room area. Licensing viewed camera footage for 2 self-harm incidents, with no concerns noted. Per CAA agreement, Licensing viewed environment of care maintenance logs (no concerns noted) and requested the new HR director attend the unit regulatory check training on 04/26/23. Licensing also followed up on a report from DSPQA IOC team that mail with confidential information was left outside unsecured at their time of visit; CEO reported she is in contact with USPS to explore options for securing mail, and Licensing requested this be completed by 03/31/23.
- Regs out of compliance –
- 912.4 – Box that toilet is in (bathroom 301) has trash, debris, and space for contraband on either side of the toilet. Facility plan is to place foam in the area, let it protrude, then cut/seal it (Complete by 03/15/23).
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-harm
- Client became escalated while in the quiet room and began to self-harm with her fingers. Staff intervened and emergency medication was administered due to client’s inability to regain a state of calm. Client calmed down and was released. Client will continue 1:1 LOS for safety.
- Licensing follow-up: Client was on 1:1 constant LOS and programming separately from peers during licensing visit. Facility has made several acute care referrals.
PRLU or OLTC
Notice of Incident, Suicide Attempt
- Suicide Attempt
- Client entered her room for quiet time and staff continued down the hall unlocking doors for peers. Approximately 1 minute later as staff was returning down the hall, staff checked client’s room and client was seen lying on the floor with a piece of material tied around her neck. Staff called for assistance and the material was removed. Client was seen breathing, conscious, and tearful but refused to verbally process. Nurse noted red area on neck where material had been tied. Orders received for 1:1 observation during wake hours while wearing paper scrubs. Client will sleep in the dayroom area for optimal supervision/safety. Therapist will continue to process with client and an individualized safety plan will be developed with therapist.
- Licensing follow-up: Licensing reviewed camera footage of incident and confirmed that client entered her room at around 11:40 am and was discovered by staff at around 11:41.5 am. Staff reported the material client used was an intact sweatshirt. During licensing visit, client was observed 1:1 with an MHT.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury
- Client picked scabs on her arm that resulted in minor bleeding. Client then attempted to attack a peer who verbalized that she would pull the fire alarm; Client pushed a staff member while trying to get to the peer. Client was placed on 1:1 observation due to increased self-harm behaviors and aggression.
- Licensing follow-up: Unannounced visit conducted this date. Acute care referral was made for client on 02/27 but she was not accepted due to staff shortage. At time of visit, client was observed 1:1 with staff and programming separately from other clients. CEO stated client is being taken outside separately for breaks and recreation.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury
- Client used fingernails to reopen an area on her cheek from a previous self-harm attempt. Minimal bleeding noted and the area was cleaned. Client will remain on self-harm precautions until safe behavior is observed.
- Licensing follow-up: Licensing reviewed documentation to confirm current self-harm safety plan is in place for client.
PRLU or OLTC
Notice of Incident, Self-Harm
- Self-Harm
- Client pulled an outlet out of the wall to self-harm with, and when redirected by staff, client continued to find contraband to self-harm with. After some time, client was placed in a physical restraint. After the restraint, client was assessed by the nurse and no abnormalities were found. Client processed with her therapist and was placed on self-harm precautions with constant LOS.
- Licensing follow-up: Camera footage was reviewed. The incident occurred in the corner of the dayroom in a camera blind spot, however, staff was with client for most of the hour of footage viewed. When staff left to check on other tasks, they always circled back to check on client within 5 minutes. Licensing also checked the area where the incident occurred, and no loose or poorly fitted outlets were observed in the area. No licensing concerns noted.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury
- Client used fingernails to reopen an area on her cheek from a previous self-harm attempt. Minimal bleeding noted and the area was cleaned. No further incidents occurred. Client will remain on self-harm precautions until safe behavior is observed.
- Licensing follow-up:Unannounced visit conducted this date. Licensing verified documentation was in place for current self-harm precautions.
PRLU or OLTC
Monitor Visit, Visit Compliance Report
- Licensing Specialist: Michele Sutton.
- Unannounced facility visit. Areas viewed: All units (blue, orange, green), classrooms, cafeteria, and grounds. Two residents on the green unit were refusing school and in bed, with a staff member in the dayroom. Licensing verified staff Q15s (supervision) were completed/current for both residents (neither resident was on an LOS safety plan). MARs reviewed for 5 residents.
- Licensing reviewed self-harm incidents and verified all have documentation for LOS precautions, and all were observed within LOS of staff. Residents had several outings this week, and facility plans to offer increased outings as incentives for positive behaviors.