Hang up calls from the front desk with no answer on call back. No emergency.
Police Report
Hang Up
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury
- Client became triggered due to another peer self-harming. Client obtained a staple and used it to make superficial abrasions on her forearm. Staff removed the staple, and the abrasions were cleaned. Client placed on self-harm precautions x 7 days.
- Licensing follow-up: During facility visit, the CEO confirmed client remains on self-harm safety plan.
PRLU or OLTC
Notice of Incident, Suicide Attempt
- Suicide Attempt
- Client became escalated due to multiple triggers and used her shirt to tie around her neck. The shirt was removed by staff and no injuries were noted. Client scored low risk on C-SSRS and was placed on suicide precautions x 7 days.
- Licensing follow-up: Licensing completed record review at facility and noted client to have updated/current self-harm safety plan and treatment plan.
PRLU or OLTC
Notice of Incident, Self-Harm
- Self-harm
- Client attempted to self-harm by biting herself and trying to hit herself in the face; Staff intervened. There were no breaks in the skin upon assessment. Client placed on self-harm and assault precautions x 7 days (client bit staff who intervened).
- Licensing follow-up: Licensing completed record review at facility and CEO confirmed that client remains on self-harm safety plan.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury
- Client began punching themselves in the face while in the bathroom, and a physical hold was initiated to maintain safety. Nurse noted client had a slight nosebleed prior to the restraint; No other injuries noted. Client placed on self-harm precautions with constant LOS.
- Licensing follow-up: Licensing completed record review at facility and CEO confirmed that client remains on self-harm safety plan.
PRLU or OLTC
Notice of Incident, Self-Harm
- Self-harm
- Client began biting themselves, with staff using blocking techniques to prevent injury. No injury was noted; Self-harm precautions continued.
- Licensing follow-up: Licensing completed record review at facility and noted client to have updated/current self-harm safety plan and treatment plan.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 1
- Client was physically restrained after breaking a light bulb in the ceiling and holding on to the broken glass. Glass was removed from client and the unit was swept clean. Client sustained 2 small cuts that were cleaned and covered. Client placed on self-harm precautions x 7 days.
- Licensing follow-up: Licensing completed record review at facility and noted client to have updated/current self-harm safety plan and documented restraint with appropriate order to initiate.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 2
- Client began scratching at forearm with fingernails, and staff intervened. Superficial scratch noted to client’s forearm. Client placed on self-harm precautions with constant LOS x 7 days.
- Licensing follow-up: Licensing completed record review at facility and noted client to have updated/current self-harm safety plan and treatment plan.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 3
- Client began punching herself in the face. Staff used blocking techniques to prevent injury and client processed with staff. Client received ice pack due to minimal swelling to side of nose. Self-harm precautions continued.
- Licensing follow-up: Licensing completed record review at facility and noted client to have updated/current self-harm safety plan.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 1
- Client attempted to use her fingernails to self-harm and attempted to bang her head on the wall. Client was taken to the comfort room, where she shut herself in the bathroom and attempted to hit herself in the face, punch the wall, and bang her head, all of which were blocked by staff. Client was able to de-escalate, and a cold pack was provided for discomfort to client’s knuckle. Self-harm precautions continued.
- Licensing follow-up: Licensing completed record review at facility and CEO confirmed that client is on self-harm and assault precautions due to recent behavioral disturbances.
PRLU or OLTC
Notice of Incident, Self-Harm
- Self-harm
- Client began punching herself in the face. Staff used blocking techniques to prevent injury and client processed with staff. No injury noted.
- Licensing follow-up: Licensing completed record review at facility and noted client to have updated/current safety plan to address her self-harm behaviors.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 2
- Client escalated due to increased sound on unit and began to pick scabs on her arms with her fingernails. Client’s wounds were cleaned and covered. Earbuds will be offered to reduce noise stimuli. Self-harm precautions continued.
- Licensing follow-up: Licensing completed record review at facility and CEO confirmed that client remains on safety plan and individualized safety contract to address her self-harm behaviors.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury
- Client hit their nose with their hand, causing it to bleed. Client processed with staff and the nurse treated and cleaned client’s nose. Self-harm precautions continued.
- Licensing follow-up: Licensing visited facility and safety plan was observed at time of visit.
PRLU or OLTC
Notice of Incident, Self-Harm
- Self-harm
- Throughout the day, client had been biting themselves with staff physically blocking client to prevent injury. Client was successful in biting self but did not cause injury. Client placed on self-harm precautions with constant LOS x 7 days.
- Licensing follow-up: Licensing visited facility and safety plan was observed at time of visit. Facility continues to utilize individualized behavior management plan with client.
PRLU or OLTC
Notice of Incident, Self-Injury, Suicide Attempt
- Suicide Attempt, Self-inflicted Injury
- Client attempted to place her hands around her neck despite staff physically blocking her, and then began to scratch her forearm with her nails. Client processed with staff, and superficial scratches were noted to client’s forearm. Self-harm precautions continued.
- Licensing follow-up: Licensing visited facility and safety plan was observed at time of visit.
PRLU or OLTC
Self Report Visit, Visit Compliance Report
- Licensing Specialist: Chelsea Vardell.
- No site visit conducted. Licensing received 3 notifications of self-harm incidents after business hours on 02/03/23 that occurred on 01/31/23.
- Regs out of compliance –
- 109.1.f – Facility failed to comply with the current Corrective Action Agreement, requiring all self-harm incidents be reported to Licensing by the next business day (3 incidents on 01/31/23).
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury
- Client was discovered in the bathroom using a small piece of a paint brush to injure her forearm. Staff intervened, and contraband was retrieved. Nurse cleaned and covered small laceration to client’s forearm. Client placed on self-harm precautions with constant LOS x 7 days.
- Licensing follow-up: Licensing visited facility and safety plan was observed at time of visit.
PRLU or OLTC
Notice of Incident, Self-Injury, Suicide Attempt
- Suicide Attempt, Self-inflicted Injury
- Client became dysregulated and placed her hands around her neck and began scratching her forearms with her fingernails. Client processed with staff and client’s nails were trimmed and filed. Nurse cleaned and covered superficial scratch to forearm. Self-harm precautions with constant LOS continued.
- Licensing follow-up: Licensing visited facility and safety plan was observed at time of visit.
PRLU or OLTC
Buildings and Grounds, Self Report Visit, Visit Compliance Report
- Licensing Specialist: Michele Sutton.
- Licensing completed visit and observed all units within ratio and all residents within LOS of staff. All bedrooms and dayrooms were viewed with no safety hazards noted. Tiles in room 205 and 305 have been repaired. The grounds remain out of use until the roofing project is completed.
- Facility provided a list of new hires for January 2023 as per CAA requirements and confirmed they no longer use temporary staffing agencies.
- Licensing followed up on recent self-harm incidents and reviewed safety plan for client who reported hiding contraband behind her bed; Contraband was removed, and facility implemented regular room searches on units. CEO is in process of training all staff on how to complete a thorough room search. Other incidents involving fingernail scratches are being addressed by staff re-training on de-escalation, ensuring residents are engaged throughout the day, and standing orders to trim/cut resident fingernails as needed.
PRLU or OLTC
Complaint Survey
Complaints #AR00029527 and #AR00029530 were in compliance.
PRLU or OLTC
Notice of Incident, Self-Harm, Suicide Attempt
- Suicide Attempt, Self-harm 1
- Client was discovered by staff in the bathroom with a sweatshirt tied around her neck. Once staff removed the shirt, client began hitting their head on the wall. Client was able to de-escalate, and no injuries were noted. Client placed on 3-day suicide precautions.
- Licensing follow-up on 02/09/23: Licensing reviewed camera footage. Facility was cited for 907.2: Client was on constant LOS self-harm precautions due to a previous incident, and staff allowed her to go to the bathroom and left her in the room unsupervised for nearly 4 minutes. Facility has suspended the staff member who failed to provide adequate supervision pending internal investigation. Licensing requested all staff are trained on supervision requirements with an emphasis on safety precaution plan supervision requirements. Staff re-education has occurred and will continue to be ongoing.
PRLU or OLTC
Notice of Incident, Self-Harm, Suicide Attempt
- Suicide Attempt, Self-harm 2
- Client became dysregulated and began hitting themselves in the face and placed their hands around their neck to cause injury to self. Client processed with staff, and mild redness was noted to client’s neck (no first aid required). Client placed on self-harm precautions with constant LOS x 7 days.
- Licensing follow-up: Licensing visited facility on 02/03/23. Current safety plan was observed at time of visit.
PRLU or OLTC
Technical Assistance, Visit Compliance Report
- Licensing Specialist: Michele Sutton.
- Several reports of self-harm incidents from 01/26/23 – 01/27/23 were received on 01/31/23. Facility did not receive copy of signed CAA until 01/30/23, and the ADON only recently (01/27/23) became responsible for reporting incidents. Moving forward, the facility will be cited for any incidents that are not reported within 1 business day of occurrence, and facility will be cited for any incidents that are not reported within the timeframes specified in the Corrective Action Agreement.
- TA –
- 109.1.f – Late reporting (6 incidents).
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 1
- Client began biting herself on her hand, leaving a superficial opening on the top of the skin. Area was cleaned by nurse. Client was placed on self-harm precautions with constant LOS x 7 days.
- Licensing follow-up: Licensing cited facility on 02/06/23 for failure to comply with stipulations set forth in the Corrective Action Agreement. Facility visited on 02/09/23; Licensing reviewed client’s safety plan and observed client within LOS of staff during visit.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 2
- Client began picking and opening old scabs on arms. Nurse cleaned area. Self-harm precautions with constant LOS continued.
- Licensing follow-up: Licensing cited facility on 02/06/23 for failure to comply with stipulations set forth in the Corrective Action Agreement. Facility visited on 02/09/23; Licensing reviewed/observed client’s safety plan during visit.