911 open line; No sounds of emergency. There are several men putting a new roof on the building, no emergencies.
Police Report
Hang Up
PRLU or OLTC
Buildings and Grounds, Visit Compliance Report
- Licensing Specialist: Michele Sutton.
- Unannounced buildings and grounds visit conducted. Orange Unit, Green Unit, classrooms, and facility grounds viewed. CEO advised that she is working to increase activities and is initiating a new behavior monitoring sheet and shift communication sheet to facilitate better communication.
- TA –
- 910.1 – Gap at bottom of outside gate is large enough for residents to pull sheet metal and other building supplies into the recreational area; Maintenance was aware and stated he talked to the work crew to ensure they clean up after each job and is monitoring the area for dangerous materials prior to residents going outside.
- 911.6 – In Room 201 of Orange Unit, toilet bowl seat needs to be replaced (replacement pending) and laminate in sink area is loose and needs to be replaced (new counter has been ordered).
Police Report
Hang Up
Hang up; No answer on call back. Staff advised no emergency.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 1
- Client began hitting herself in the nose after becoming overstimulated. RN intervened and noted mild bleeding around nose. Client washed face and hands, and no injury was apparent. Client will be placed on self-harm precaution safety plan with increased LOS.
- Licensing follow-up: DON advised Licensing that client has been placed on self-harm precautions, constant LOS, and facility is working to re-direct behaviors. Licensing visited facility on 01/19/23; Client remains on constant LOS precautions and facility is working on identifying specific interventions.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 2
- Client used her fingernails to scratch her inner arm. Staff intervened and nurse assessed, noting 2 new superficial scratches to left inner forearm with some disturbed scabs of old scratches. Client’s arms were cleaned, and coverings placed. Client’s current self-harm precaution safety plan with constant LOS to be extended.
- Licensing follow-up: No additional licensing follow-up required at this time.
PRLU or OLTC
Notice of Incident, Suicide Attempt
- Suicide Attempt
- Client took her hygiene towel and wrapped it around her neck while in the shower. Staff intervened and removed the towel promptly. Mild redness noted to client’s neck. C-SSRS performed, and client scored high risk. Suicide precaution safety plan with constant LOS initiated.
- Licensing follow-up: On 01/24/23, Licensing reviewed safety plan which is current and reflects self-injurious behaviors and interventions.
Police Report
Alarm
Commercial burglary alarm. Building secured.
Police Report
Hang Up
Caller was heard stating “Oh, my bad” and then they disconnected. Staff advised no emergency.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 1
- Client began hitting herself in the nose after becoming overstimulated. RN intervened and noted mild bleeding around nose. Client washed face and hands, and no injury was apparent. Client will be placed on self-harm precaution safety plan with increased LOS.
- Licensing follow-up: Precautions observed at facility visit on 01/09/23. No additional follow-up required at this time.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 2
- Client stood and banged their head against the wall after reports of feeling impulsive and overstimulated. The existing nodule in the middle of client’s forehead noted to be raised with mild bleeding present; Area cleaned. C-SSRS performed, and client continues to score low risk for suicide. It is reported by the client that they have been performing this “head banging” behavior since they were about 10 y/o as a way to cope. Client will remain on self-harm precaution safety plan with constant LOS.
- Licensing follow-up: Precautions observed at facility visit on 01/09/23. No additional follow-up required at this time.
PRLU or OLTC
Buildings and Grounds, Visit Compliance Report
- Licensing Specialist: Michele Sutton.
- Licensing conducted a follow up targeted buildings/grounds visit to determine if there were any safety hazards or self-harm implements on the blue unit, green unit, or cafeteria. No citations in areas viewed.
Police Report
Alarm
Commercial burglary alarm. Building secured.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury
- Client returned to their unit after a phone call and used small pieces of plastic to make 2 superficial scratches to their left forearm. The contraband was removed, and the scratches were cleaned and covered. Self-harm precaution safety plan was implemented. C-SSRS performed with client scoring zero.
- Licensing follow-up: Licensing observed unit during facility visit. Unit was in ratio and no safety concerns/maintenance issues were identified. Licensing did not view client’s room as she was standing in front of the door stating she “hates DHS”. DON stated client is on self-harm precautions and facility staff will monitor her room for safety.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury
- Client used plastic cap to make superficial cuts to their arm. Client’s wound was cleaned, and self-harm safety plan extended. The plastic cap was from a Christmas present that client received; This was given to staff.
- Licensing follow-up: During facility visit, Licensing followed up with staff regarding client’s frequent self-harm behaviors. Client’s therapist stated that due to client’s chronic self-harm behaviors that haven’t increased or changed, an acute referral is not appropriate at this time. Facility has implemented a no plastic policy on the units. Licensing reviewed LOS documentation and safety plan for client and checked her room for obvious safety hazards. The loose screw in her room was fixed and no contraband was found.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 1
- Client stood on a cafeteria table and attempted to use the plastic pieces of the light cover to cut her arm. Additional staff arrived and talked client into getting off table. Nurse assessed and noted client’s arm to have superficial scrapes over existing wounds that required no first aid. Client was placed on 1:1 status and RTU.
- Licensing follow-up: During facility visit, staff provided LOS and safety plan documentation. Client was observed to be 1:1 with an MHP during visit. Staff reported the care team plans to have a meeting to determine if a referral to an acute facility is needed for client.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 3
- Client used pieces from their soap bottle to make superficial cuts to their arm. No first aid required; Contraband was removed. Self-harm and Suicide Precaution safety plans initiated after event and response to C-SSRS scale.
- Licensing follow-up: During facility visit, Licensing followed up with staff regarding client’s frequent self-harm behaviors. Client’s therapist stated that due to client’s chronic self-harm behaviors that haven’t increased or changed, an acute referral is not appropriate at this time. Facility has implemented a no plastic policy on the units. Licensing reviewed LOS documentation and safety plan for client and checked her room for obvious safety hazards. The loose screw in her room was fixed and no contraband was found.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury 2
- Client used the tip of her glasses to poke a hole in her skin (left forearm), about the size of a small nail. The glasses were turned in to the RN. Client’s wound was cleaned with no further medical attention needed. Client was placed on self-harm precautions x 7 days.
- Licensing follow-up: Client is currently on LOS precautions per her safety plan. No additional follow-up required at this time.
Police Report
Hang Up
Hang up; No sounds of distress. No answer on call back. Staff advised no emergency.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury
- Client stood on a cafeteria table and attempted to use the plastic pieces of the light cover to cut her arm. Additional staff arrived and talked client into getting off table. Nurse assessed and noted client’s arm to have superficial scrapes over existing wounds that required no first aid. Client was placed on 1:1 status and RTU.
- Licensing follow-up: During facility visit, staff provided LOS and safety plan documentation. Client was observed to be 1:1 with an MHP during visit. Staff reported the care team plans to have a meeting to determine if a referral to an acute facility is needed for client.
PRLU or OLTC
Self Report Visit, Visit Compliance Report
- Licensing Specialist: Chelsea Vardell
- Licensing visited facility and discussed 3 incidents of self-harm by client on 12/11/22 (used broken light socket cover), 12/13/22 (used piece of shampoo bottle), and 12/23/22 (threatened to swallow screw). Licensing conducted walkthrough and cited facility for several issues found. Licensing encouraged facility to document how and when staff are complying with any doctor’s orders (safety precautions) and discussed the facility using paper cups with hygiene products to eliminate residents using plastic bottles to self-harm.
- Regs out of compliance –
- 9.911.6 – Loose outlet covers (2) in the cafeteria, protruding screw in the window of room 305, and broken light switch cover reportedly used to self-harm by client on 12/11/22 (already corrected). Repair by 12/30/22.
PRLU or OLTC
Notice of Incident, Suicide Attempt
- Suicide Attempt
- Client tore the elastic piece from the waist band of her paper scrubs and attempted to tie it around her neck. Staff intervened and no injuries were noted. Client will remain on suicide precautions x 7 days and will stay in paper scrubs. Resident scored high on C-SSRS.
- Licensing follow-up: The client is not being assessed for acute care, because it is believed the attempts are more attention seeking behaviors as the client could not reach her parents via telephone for the holidays. The client has had no reported self-harm attempts since she was able to reach her parents via phone.
PRLU or OLTC
Notice of Incident, Self-Injury, Visit Compliance Report
- Self-inflicted Injury (1)
- Client self-harmed with a staff bathroom key that was left on the common room table by staff. Client created 2 superficial wounds on her arm that were cleaned.
- Licensing follow-up: Facility visited on 12/29/22. It was determined that a few weeks ago, staff were allowed to use a single restroom on each unit as a “staff bathroom” so that staff did not have to leave the unit out of ratio to use the restroom on the administration hall. After the key was left out on the table, a resident used it to self-harm. DON stated the keys were collected and the unit bathroom for staff no longer allowed, but stated someone must have returned the key to the unit. DON stated this could have been due to staff shortages during the holiday. The key has again been collected and is no longer on the unit. Facility cited 907.2 for lack of supervision, as client was noted to be high risk for self-harm and had an event earlier in the day.
PRLU or OLTC
Notice of Incident, Self-Injury
- Self-inflicted Injury (2)
- Due to noise on the unit, client used her fingernail to create 2 fingertip sized scratches on her arms. The wounds were cleaned, and client was placed on self-harm precautions x 7 days. Order was restored to the unit.
- Licensing follow-up: The incident report was reviewed and determined to have no further investigation needed.
PRLU or OLTC
Notice of Incident, Self-Injury, Visit Compliance Report
- Self-inflicted Injury (3)
- Client used an eyebrow razor to make 4 superficial cuts that were already healing. Client got the razor from “makeup day” when staff brought in their own makeup products and client stole the razor from a makeup bag.
- Licensing follow-up: Facility visited on 12/29/22. DON reported that staff are no longer allowed to bring in outside makeup to be used on residents and moving forward, “makeup day” will only be allowed for residents on a certain treatment level as a reward. The facility will then purchase that makeup for the resident to ensure no cross contamination occurs with sharing makeup.
- Facility cited for 907.2 (for lack of supervision, as client had already self-harmed 2 other times earlier in the day and was on active self-harm precautions) and 910.1 (grounds shall be kept free of safety hazards).
PRLU or OLTC
Notice of Incident, Suicide Attempt
- Suicide Attempt
- Client picked and scratched at her arms with her nails, then ripped off a piece of her shirt and wrapped it around her neck. Staff intervened and removed object; Reddened area noted to client’s neck. Client admitted she wanted to hurt herself and agreed to wear paper scrubs. Client scored high on C-SSRS and will be on suicide precautions x 7 days.
- Licensing follow-up: Facility visited on 12/29/22. Licensing inquired why the client was not assessed for self-harm if she was considered “high risk”; DON reported that the attempts were believed to be client’s response after she was unable to reach her parents on the phone during the holidays. Once the client was able to reach her parents, she has not had another self-harm event.