Extra patrol (1839 hours); Complaint only.
Police Report
Extra Patrol
Police Report
Extra Patrol
Extra patrol (1914 hours); Complaint only.
PRLU or OLTC
Complaint, Notice of Incident, Visit Compliance Report
- Complaint
- During a buildings and grounds walkthrough, multiple residents expressed concerns about the facility.
- Licensing follow-up: On 11/17/22, Licensing interviewed residents and staff, and reviewed camera footage. Complaints:
- 1) Client reported she doesn’t feel safe, and stated a staff member called her and her mother “nasty.” Client alleges the staff member stated “get the girl away from me because if she comes over here, she’ll have to fight me” (Video reviewed, Licensing couldn’t determine what was said; Unfounded).
- 2) Client stated staff member is “always” telling one resident what another resident is saying about them, and stated a staff member can corroborate this. She also reported safety concerns (founded, cited 911.6), 2 residents self-harming with staples, and not having a hairbrush or conditioner.
- 3) Client concerned about “black mold” on unit and lack of soap (citation & TA provided), and a sexual assault report not followed up on (Licensing verified report was investigated by state police).
- Regs out of compliance –
- 911.6 – Showers not draining properly (correct by 12/17/22), black substance around skylight feature on blue unit (repair by 11/25/22), exposed outlet with wire and screws behind a chair in the orange unit dayroom (repaired on-site).
- TA –
- 912.6 – No soap found in any bathroom on the unit or day areas.
- 914.8 – Ensure severe weather drills are completed quarterly (facility reported they believed they were required every 6 months).
- Revisit on 11/23/22: Drains in the process of being repaired (partially completed), wall plate was replaced, black substance cleaned and painted. Staff informed Licensing that residents are allowed a hairbrush and conditioner only during hygiene, and that upon request, residents are provided a small cup of liquid soap to wash their hands. MARs reviewed for 5 residents. No licensing concerns noted.
PRLU or OLTC
Attempted Assault, Notice of Incident, Visit Compliance Report
- Attempted Assault
- Client began threatening to attack a staff member who she had a verbal disagreement with earlier, as well as peers. Client jumped on the nurse’s station and began throwing items, then picked up the phone and dialed 911, stating she “wants to go to jail.” Police were dispatched due to the call, and client was placed in handcuffs after attempting to push past officers. Once client was able to calm down, handcuffs were removed. Minimal redness noted to client’s wrists. Assault precaution safety plan was extended.
- Licensing follow-up: Facility visited on 11/23/22 and camera footage reviewed (no audio). At no time was staff observed arguing with the client. Staff reported the telephone was moved to the YCC office and is brought out for telephone time, and all papers/notebooks will be kept in the nurse’s office. No licensing concerns noted.
Police Report
Assault
Officer responded to facility after dispatch received a 911 hang up, in which a male and female were heard yelling at each other. Upon arrival, officer observed juvenile banging on a locked door, yelling at people on the other side of the door. Juvenile was detained in handcuffs after being noncompliant and threatening to “kill all the hoes”. Juvenile stated she had called the police and advised an employee threw a chair at her earlier. Officer spoke with staff member, who stated the girls had been allowed to put makeup on themselves and after wipes were left out with makeup on them, staff stated it was “nasty”. Staff stated juvenile took it as staff calling her nasty, and juvenile threw a binder at her and spit on her before police arrived. Officer issued juvenile a citation for Assault 2nd.
PRLU or OLTC
Notice of Incident, Self-Injury, Suicide Attempt, Visit Compliance Report
- Suicide Attempt, Self-inflicted Injury
- Client attempted to scratch arm on door frame and get to outlets in the dayroom. Once taken to the comfort room, client attempted to choke herself with her hands, and began digging her nails into her skin to “get to the vein.” Upon assessment, small circular breaks in the skin were noted from client’s fingernails, with redness and minimal bleeding. Client was placed on suicide and self-harm precautions and placed in paper scrubs.
- Licensing follow-up: Facility visited on 11/23/22 and camera footage reviewed. Licensing also checked the door frame and felt no rough edges when rubbing hand and wrist across the rounded screws. No licensing concerns noted.
PRLU or OLTC
Licensing, Notice of Incident, Self-Harm, Suicide Attempt
- Licensing (Suicide Attempt, Self-harm)
- Client attempted to scratch arm on a door frame and get to outlets in the dayroom. Once in the comfort room, client attempted to choke herself by putting her hands around her neck and began digging her nails in her skin. Nurse assessed client and noted small circular breaks in the skin and redness with minimal bleeding; No first aid required. Client was able to self-regulate and per the C-SSRS results, client was high-risk and placed on suicide and self-harm precautions and in paper scrubs for safety. No follow-up details.
PRLU or OLTC
Licensing Follow Up, Notice of Incident, Suicide Attempt
- Licensing (Suicide Attempt)
- Client wrapped a towel around her neck after a verbal altercation with peer. Staff removed the towel, and no marks or redness was noted. Per the C-SSRS results, client was high-risk and will remain on suicide precautions for 7 days. Client placed on Constant LOS and took PRN medication.
- Licensing follow-up: Specialist was informed that the PRN medication is documented on the MARs and is set up as needed medication and PRNs are already prescribed and available as needed. No licensing concerns noted.
PRLU or OLTC
Children's Records Review, Personnel Record Review, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 11:20am – 3:30pm; Census: 26. Licensing reviewed 1 personnel file and 5 children’s charts with no licensing concerns noted. Licensing was informed that the facility’s boundary training started on 11/09/22 and the completion date to have all personnel trained is 11/11/22.
PRLU or OLTC
Licensing Follow Up, Notice of Incident
- Licensing (JDC)
- Client stated she intended to “kick-punch everyone until I get to leave with the police.” Client was placed in a restraint after attempting to destroy the fire extinguisher and threw a walkie talkie at staff. During restraint, an emergency call was heard for Green Unit and 2 staff left the restraint to address the issue w/o nurse directive. Another hold was initiated after client attempted to trigger fire alarm and punched staff who intervened. Shortly after restraint, client attempted to break into the med room, resulting in a hold. Client assaulted staff during restraints, and after attempting to assault officer, was taken into police custody. As of 11/9/22, client remains at Washington County JDC.
- Licensing follow-up: Specialist viewed camera footage of incident and reviewed the incident report log and restraint documentation. No licensing concerns noted.
Police Report
Assault, Disturbance
At 0849 hours, officer responded after caller advised juvenile was aggressive and fighting with staff, and had to be held down. Officer left the facility, as juvenile had not committed a crime. At 0924 hours, officer responded again after staff reported the juvenile had set off the fire alarm and forced her way into the medicine room. While staff were removing her from the med room, juvenile bit staff member on the back, leaving a red mark. Officer charged juvenile with battery 2nd felony and transported juvenile to JDC.
PRLU or OLTC
Licensing Follow Up, Notice of Incident, Self-Harm
- Licensing (Self-harm)
- Client used a toothbrush she broke to make superficial cuts on her forearm. The scratches were cleaned, and a self-harm safety plan was initiated for 7 days.
- Licensing follow-up: DON informed Specialist that the incident took place in the client’s bedroom bathroom, where there are no cameras. On 11/17/22, the Specialist was informed the client was doing better with no further incidents reported.
PRLU or OLTC
Complaint Survey with POC, Revisit Survey
- Complaint #AR00028965 was not in compliance, all or in part, with deficiencies cited at N132, N215, and N216.
- Complaint #AR00029061 was in compliance.
- Regs out of compliance –
- N132 – Failed to ensure a physical hold of Client #1 was performed in a safe manner.
- N215 – Failed to ensure a Certified Nursing Assistant, hired through an agency, had received Satori Alternatives to Manage Aggression (SAMA) training for the safe use of restraints prior to placing Client #1 in a restraint.
- N216 – Failed to ensure a Certified Nursing Assistant, hired through an agency, had received training on de-escalation techniques prior to placing Client #1 in a restraint.
- POC – All direct care staff will complete a full SAMA class and refresher course by a certified instructor regarding de-escalation and holding techniques. DON will complete camera review of all safety interventions to ensure physical holds are completed in a safe manner. HR will schedule any staff hired through an agency to attend a new hire orientation prior to being placed in the milieu. HR has audited all personnel files to ensure training compliance and will report training compliance weekly to CEO, DON, and Corporate Risk Manager.
- A revisit was conducted on 12/21/22 for all deficiencies cited on 11/04/22. All deficiencies have been corrected, and no new noncompliance was found.
PRLU or OLTC
Accidental Injury, Elopement, Licensing Follow Up, Notice of Incident
- Licensing (Elopement, Accidental Injury)
- After a resident broke a fire sprinkler head, the fire alarms were activated. During the event, client ran off the milieu into the back courtyard where she climbed the fence and took off on foot away from facility. Staff were able to bring client back to the facility. Upon return, client was taken to the med room for a bilateral minimal superficial laceration on her arm from jumping the fence. Client charged into the med room and staff support was called to assist. Once out of the med room, client was detained after kicking and pushing at law enforcement. Client presented with symptoms of psychosis/head injury and was taken to the hospital. Client returned to facility and was placed on assault safety plan for 7 days.
- Licensing follow-up: Specialist viewed camera footage on 11/3/22. Licensing visited the facility regarding complaints received on 10/7/22 and 10/28/22, and 11/01/22 incident. Licensing viewed camera footage for 11/1/22 incident and cited facility for R907.2 (resident was allowed to use a broom unsupervised). TA provided on de-escalation and a draft copy of their de-escalation process was provided to Licensing Specialist.
PRLU or OLTC
Licensing Follow Up, Notice of Incident, Panic Attack
- Licensing (Panic Attack)
- After a resident broke a fire sprinkler head, the fire alarms were activated. During the event, client reports she slipped and fell on water and was noted to be having a very severe panic attack. Client was taken to the hospital, and injuries associated with her event were ruled out. Client returned to facility once discharged from the hospital.
- Licensing follow-up: Specialist viewed camera footage on 11/3/22. Due to several incidents taking place on the viewed footage, Specialist could not determine which resident fell. Licensing visited the facility regarding complaints received on 10/7/22 and 10/28/22, and 11/01/22 incident. Licensing viewed camera footage for 11/1/22 incident and cited facility for R907.2 (resident was allowed to use a broom unsupervised). TA provided on de-escalation and a draft copy of their de-escalation process was provided to Licensing Specialist.
PRLU or OLTC
Licensing Follow Up, Notice of Incident, Peer Altercation
- Licensing (Peer Altercation)
- After a resident broke a fire sprinkler head, the fire alarms were activated. During the event, client began yelling and screaming obscenities at peers, dysregulating multiple residents. Client began throwing cups of water, punching staff who attempted to intervene, and got into an altercation with a peer that was promptly separated. Client was placed in a restraint after punching a nurse in the head. Client complained of head pain while in the restraint and was taken to the hospital. Client returned to facility and was placed on assault safety plan for 7 days and will remain 1:1 with staff.
- Licensing follow-up: Specialist viewed camera footage on 11/3/22 and observed client’s aggressive behavior and noted client appeared to be having a panic/anxiety attack. Licensing visited the facility regarding complaints received on 10/7/22 and 10/28/22, and 11/01/22 incident. Licensing viewed camera footage for 11/1/22 incident and cited facility for R907.2 (resident was allowed to use a broom unsupervised). TA provided on de-escalation and a draft copy of their de-escalation process was provided to Licensing Specialist.
PRLU or OLTC
Licensing Follow Up, Notice of Incident, Suicide Attempt
- Licensing (Suicide Attempt)
- After a resident broke a fire sprinkler head, the fire alarms were activated. During the event, client became dysregulated and attempted to tie her shirt around her neck and jump the nurse’s station to get items to self-harm with. Client became assaultive with staff and police who tried to intervene. Client was detained, and after complaining of neck pain, was taken to the hospital. Client was placed on assault safety plan for 7 days.
- Licensing follow-up: Specialist viewed camera footage on 11/3/22. Specialist was informed the client was in acute care at Springwoods. Licensing visited the facility regarding complaints received on 10/7/22 and 10/28/22, and 11/01/22 incident. Licensing viewed camera footage for 11/1/22 incident and cited facility for R907.2 (resident was allowed to use a broom unsupervised). TA provided on de-escalation and a draft copy of their de-escalation process was provided to Licensing Specialist.
Police Report
Assault & Battery, Disturbance
Caller (juvenile) stated there was a riot at the facility and kids are trying to fight; Caller advised “send everyone you have.” People screaming in background. Dispatch received multiple calls regarding riot that started after a fire alarm was pulled. Upon arrival, officers advised a juvenile was unconscious and 2 juveniles fled the facility. A juvenile was transported to ER for suicidal ideations and another was transported to ER for cutting her wrist. After a head count, all juveniles were accounted for. Staff advised they wanted to press charges on 2 juveniles, and would call back when they had all information needed.
PRLU or OLTC
Licensing, Notice of Incident, Suicide Attempt
- Licensing (Suicide Attempt)
- Client became upset after a verbal disagreement with peer and went to the bathroom. Client would not answer staff after several prompts, and staff entered bathroom and found client on the floor attempting to tighten her paper scrubs around her neck. Staff removed scrubs and took client off unit, where she jumped on the nurse’s station and grabbed the phone. Staff removed the phone, and client was able to process and took her PRN anxiety medication. Client placed on suicide and assault precaution safety plans for 7 days.
- Licensing follow-up: Facility reported that on 11/1/22, client was sent to the hospital and then to acute care. Client was discharged from facility the same day. No licensing concerns noted.
PRLU or OLTC
Licensing Follow Up, Notice of Incident, Self-Harm, Suicide Attempt
- Licensing (Suicide Attempt, Self-harm)
- Client became upset on unit and wrapped a piece of clothing around her neck. Staff removed item from client’s neck. Client continued to search for items to wrap around her neck and items to scrape across her arm. Client used her fingernails to pick at her inner arm. After throwing objects and attempting to hit, kick, and bite staff, client was able to calm down. Client scored moderate risk for suicide per C-SSRS scale. Client will remain on suicide risk and self-harm safety precautions and remains in paper scrubs. Minimal redness noted on neck, several small pinch marks and slight openings in skin noted on inner arms. First aid applied.
- Licensing follow-up: DON informed Specialist of self-harm items used; No licensing concerns noted.
PRLU or OLTC
Licensing Follow Up, Notice of Incident, Self-Harm
- Licensing (Self-harm)
- Client became upset after finding some of her items had been damaged by a peer that was dysregulated. Client began banging on door, throwing peers belongings, and bit a plastic piece off a marker and began scraping it across her arm. After plastic piece was removed by staff, client attempted to bite off a light socket and was put in a physical restraint. Client scored high on C-SSRS and verbalized active plan to commit suicide with intent. Client placed on strict 1:1 throughout night and facility began search for acute placement, but search was called off the next day as client was doing better and scored low on C-SSRS scale. Client was placed on Constant LOS, suicide risk and self-harm precautions. Scratches noted on client’s arms caused from plastic and client’s fingernails.
- Licensing follow-up: Specialist reviewed client’s file on 11/9/22. Documentation of restraints and physician’s orders were provided. No licensing concerns noted.
PRLU or OLTC
Licensing Follow Up, Notice of Incident, Suicide Attempt
- Licensing (Suicide Attempt) 1
- Client pushed past staff and got off unit without permission. Client threw cups of water and hit and kicked staff. While in the comfort room, client removed part of the foam floor and wrapped it around her neck. Staff removed item; No injuries occurred. Client was able to calm down and return to unit. About an hour later, client got off the unit and repeated the same behaviors. Client was eventually able to calm down and return to unit. Client placed on suicide risk, self-harm, assault, and property destruction precautions.
- Licensing follow-up: On 11/14/22, DON informed Specialist that a high-quality adhesive was applied to the foam floor to prevent residents from pulling up the foam. No licensing concerns noted.
PRLU or OLTC
Licensing Follow Up, Notice of Incident, Suicide Attempt
- Licensing (Suicide Attempt) 2
- Client became upset and attempted to push past staff to get off the unit, during which client removed her shirt and tied it around her neck. Staff removed shirt and processed with client; Client scored moderate risk for suicide per C-SSRS scale. Client was placed on Constant LOS, suicide risk, and self-harm safety precautions for 7 days, and paper scrubs were provided for safety.
- Licensing follow-up: DON informed Specialist of safety precautions; No licensing concerns noted.
PRLU or OLTC
Recommendation for Probationary License
PRLU or OLTC
Complaint, Licensing Follow Up, Notice of Incident, Visit Compliance Report
- Licensing (Complaint)
- Complainant stated 2 staff members withheld water from the orange unit as a punishment. When asked for by the residents, staff stated they were withholding it until the residents calmed down. Complainant stated a staff member does not give bathroom breaks and makes staff wait for over an hour, indicating they are still assigning only 1 staff per dorm. Complainant reported a staff member yells and berates residents and puts residents and staff at risk (e.g.: She told a staff member to stand in a resident’s room alone while they shower and do “Marco Polo”; She told 2 staff members to completely ignore a kid if they appear to be having a seizure; She tells new staff that orientation kids can immediately sleep in their rooms instead of in the dayroom for the required 5-7 days of Constant LOS).
- Licensing follow-up: Specialist requested additional information and work schedules of staff named in complaint. As of 10/31/22, facility reported the first staff member is no longer with the agency (terminated for improper use of a restraint), and the second staff member will be doing administrative duties until further notice. Licensing visited facility on 11/3/22 and interviewed 4 residents; When asked if there were any concerns regarding staff members, both staff were mentioned. Specialist interviewed staff still employed, who stated she felt like she was retaliated against for writing up a staff member. On 11/15/22, facility DON informed specialist that documentation of the write-up that the alleged staff member completed on an employee had not been produced. No licensing concerns noted. Complaint unfounded.