Caller reported juvenile has passed out twice, BP is 86/58 and pulse 118. Juvenile transported to hospital.
Police Report
Call Report, Medical
Medicaid Inspection of Care
Inspection of Care Follow Up Report
- Included: IOC (follow up report), CAP
- Multiple deficiencies noted. CAP must be completed within 30 calendar days (CAP submitted and approved).
PRLU or OLTC
Complaint, Notice of Incident, Visit Compliance Report
- Complaint
- Complaint received stating client was given the incorrect dose of medication which lead to increased aggression and harm to others. Client was then discharged, and parents were notified via email that they had 72 hours to pick the patient up, 15 hours away. No aftercare plans were made.
- Licensing follow-up: Licensing reviewed client records. Client was admitted on 11/28/22 and arrived with limited paperwork and bottles of pills (a 60 mg bottle and 80 mg bottle). The nurse assumed the 80 mg bottle was the current dosage, but the actual dosage prescribed was 140 mg. The APRN signed off on the medications after reviewing and adjusting them the following morning. The guardians were notified of the adjustments but were not provided a full list of current meds which would have reflected the lower dose of the specific medication she arrived with. Client exhibited violent behaviors throughout her stay, prompting an emergency 72-hour discharge on 12/20/22. The guardians were then provided a list of medications upon discharge, and they discovered the incorrect dose of medication. CEO advised that the client had several aggressive/violent behaviors at her previous facility, therefore, the facility does not believe the medication changes caused behavior prompting emergency discharge. Licensing investigated this complaint and provided TA on 01/04/23 regarding standard 902.10.f. Licensing complaint unfounded. DON stated that moving forward, the facility plans to complete a nurse review and medication reconciliation for each new resident to ensure meds/dosages are correct and will follow-up with guardian to ensure accuracy.
PRLU or OLTC
Notice of Incident, Property Damage
- Property Damage
- Client damaged the fire sprinkler resulting in the fire alarm being triggered, and widespread flooding through the units/milieu. All residents were taken to the back courtyard until deemed safe by the fire department. Once back inside, client stated she planned to elope but was unable to do so. Client was placed on attempted elopement precaution safety plan with constant line of sight, and property destruction safety plan.
- Licensing follow-up: Facility visited on 12/29/22 and camera footage reviewed. The client is observed escalating and begins destroying and throwing items, then picks up a Lysol bottle that was left out and proceeds to get on a chair and hit the sprinkler with it. Client gets on and off the chair 2 times, hitting the sprinkler both times, before getting on the chair the third time and activating the sprinkler and fire alarm.
- The facility was cited for 910.1: Lysol was left unattended, allowing the client to obtain it. TA was provided for 905.10: Staff did not intervene while the client attempted to damage the fire sprinkler multiple times before she was successful.
Police Report
Alarm
Keyholder requested dispatch for burglary alarm. Building secured.
PRLU or OLTC
Notice of Incident, Self-Injury, Visit Compliance Report
- Self-inflicted Injury
- Client reported self-harming in the shower using a shampoo bottle. Superficial scratches noted to right forearm. Body and room search completed, and client was placed on self-harm precautions including LOS showers x 7 days.
- Licensing follow-up: Licensing visited facility on 12/29/22. Licensing discussed ways facility can ensure staff are following all doctor’s orders regarding self-harm safety plans and the option of using paper cups for hygiene products to ensure residents do not use bottles to self-harm with. Facility was cited for several safety issues (see 12/29/22 Visit Compliance Report). The facility was also cited for 109.1.f due to not reporting the incident to licensing by the next business day (violation of their corrective action agreement).
PRLU or OLTC
Buildings and Grounds, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 9:30am – 10:30am; Census: 30. Blue Unit, Green Unit, and classrooms viewed. Licensing was informed that the new CEO will be starting on 01/04/23. MARs reviewed for 5 residents. No licensing concerns noted.
PRLU or OLTC
Notice of Incident, Self-Harm, Visit Compliance Report
- Self-harm
- Client was involved in several verbal altercations with peers and was placed in a restraint after becoming dysregulated and attempting to damage property. Client calmed but became angry again after she was told she could not join her peers in the cafeteria for dinner. Client entered the hygiene closet and locked herself inside. Staff remained by the door and attempted to make entry until client decided to open the door. Client was placed in another restraint, during which she began banging her head on the floor and bit staff on the ankle. Client received a chemical restraint, after which she calmed down. No injuries noted. Client was placed on assault precaution safety plan.
- Licensing follow-up: Facility visited on 12/29/22. Licensing discussed with staff alternative ways to ensure the hygiene door cannot lock from the inside. Staff reported a mechanism on the inside of the lock can be disabled; This will be completed by 12/30/22. The facility was cited for 109.1.f due to not reporting the incident to licensing by the next business day (violation of their corrective action agreement).
PRLU or OLTC
Notice of Incident, Self-Injury, Visit Compliance Report
- Self-inflicted Injury
- Client self-harmed with light socket cover on her forearm. The wounds were superficial and cleaned with soap and water. Client placed on self-harm precaution x 7 days.
- Licensing follow-up: Licensing visited the facility on 12/29/22 and observed the resident’s bathroom light socket was replaced. Licensing discussed self-harm precautions with staff, and the facility was cited for several safety issues (see 12/29/22 Visit Compliance Report). The facility was also cited for 109.1.f due to not reporting the incident to licensing by the next business day (violation of their corrective action agreement).
PRLU or OLTC
Buildings and Grounds, Visit Compliance Report
- Licensing Specialist: Michele Sutton.
- Unannounced buildings and grounds visit completed. Licensing viewed green, blue, and orange units and grounds. Blue unit was recently painted and the unknown black substance around the skylight was removed and painted over. Shower drains have been repaired and tested to ensure they were draining properly. No citations in areas viewed.
PRLU or OLTC
Notice of Incident, Self-Injury, Visit Compliance Report
- Self-inflicted Injury
- Client used fingers to create superficial wound on her left arm. Wound was washed with soap and water. Client was placed on self-harm precautions x 7 days.
- Licensing follow-up: The facility was cited for 109.1.f due to not reporting the incident to licensing by the next business day (violation of their corrective action agreement).
Police Report
Alarm
Caller requested dispatch. “Got sent to the hotline that is 24/7”; “Building secure.”
PRLU or OLTC
Notice of Incident, Self-Injury, Visit Compliance Report
- Self-inflicted Injury
- Client hit head against wall for a short period resulting in a small circular bump in center of forehead. Client refused treatment for injury. Client placed on self-harm safety precautions.
- Licensing follow-up: The facility was cited for 109.1.f due to not reporting the incident to licensing by the next business day (violation of their corrective action agreement).
Medicaid Inspection of Care
- DMS imposes the following sanctions, based on findings from 10/21/22 Inspection of Care, and monitoring visits on 03/29/22, 07/20/22, and 10/13/22:
- Placement in high priority monitoring status;
- Submission of a Corrective Action Plan that addresses the deficiencies related to the missing treatment plans, to be submitted to DMS within 30 days of receipt of this notice;
- DMS will be reporting the facility to its accrediting agency.
PRLU or OLTC
Monitor Visit, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 11:30am – 1:15pm; Census: 26. Licensing inquired about de-escalation training that the CEO was waiting on approval from corporate. Interim CEO reported that the CEO is no longer employed at the facility and that all staff get de-escalation training during their SAMA training and annually. A roster was provided of staff that completed SAMA and annual training. No licensing concerns noted.
PRLU or OLTC
Elopement, Notice of Incident, Visit Compliance Report
- Elopements
- At approximately 4:08 pm, Client 1 conspired with peers to pull the fire alarm with a set of keys she had stolen. Client 1 entered the employee breakroom and stole car keys and the wallet of a staff member, then fled facility grounds in staff’s car with Client 2. Client 3 eloped from the facility separately. Police were notified. Clients 1 & 2 were picked up by Conway PD and transported to JDC; Client 1 did not return to the facility and was picked up by AR DHS, and Client 2 returned to the facility and was placed on elopement precautions, line of sight, and placed in paper scrubs. Client 3 was located by Springdale PD 2-3 hours later; She returned to the facility and was placed on elopement precautions and line of sight.
- Licensing follow-up: Facility visited on 11/29/22 and camera footage reviewed. Licensing was informed that when the resident pulled the fire alarm and ran out of the gym, staff did not follow her but informed other staff and called the police. The resident then entered the breakroom and stole the keys and wallet. The other 2 residents eloped after being escorted outside due to the fire alarm. No licensing concerns noted.
Police Report
Missing Person, Runaway, Theft of Vehicle
At 1614 hours, staff called to report a child missing after the fire alarm was activated and doors unlocked; Shortly after, staff advised all children were accounted for. At 1637 hours, staff advised dispatch a juvenile fled the facility. Upon officer’s arrival, staff stated there were 2 missing juveniles. Staff stated J1 pulled the fire alarm and grabbed a wallet, backpack, cigarettes, and a lighter, then walked outside and left in a staff member’s vehicle. Staff later noticed J2 was missing and were unsure how she left the facility. At 1739 hours, staff called dispatch to advise of another missing juvenile that ran out of the facility when the fire alarm was pulled. J3 was located by police at approximately 8:10pm. At approximately 2319 hours, J1 & J2 were located by State Police near Plumerville.
PRLU or OLTC
Complaint Visit, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 10:15am – 12:30pm; Census: 24. Licensing inquired about boundary training, and the CEO reported that all staff have completed boundary training (Maintaining Healthy Boundaries) except for 3 PRN staff members. CEO stated those staff will not be able to work until they have completed the training. Copies of the sign-in sheets were provided. No licensing concerns noted.
PRLU or OLTC
Maltreatment, Notice of Incident, Visit Compliance Report
- Maltreatment
- It was reported by residents and staff that 2 residents were allowed to use a vape by a staff member while on transportation to an outside medical facility. The staff member was terminated from the facility on 11/22/22, and the staff member who reported it received a verbal and final written warning. Residents and their belongings were searched and nothing was found.
- Licensing follow-up: Licensing spoke with staff, who stated the 2 residents were being taken to the ER for a stomachache and strep throat. The alleged staff member transported them, along with a new staff member who reported the incident. When asked about the incident by management, the alleged staff member stated “something like that may have happened” and refused to discuss it further. The staff member was immediately terminated. A sweep of the facility was conducted and no vape pen was recovered. Child Abuse Hotline call was screened out. Licensing was provided with the discharge papers for the ER visits, witness statement from staff, phone numbers of the staff members, and corrective action plan. Facility was cited for 907.2 (staff failed to provide the level of supervision to ensure the safety and well-being of the residents).
PRLU or OLTC
Notice of Incident, Suicide Attempt, Visit Compliance Report
- Suicide Attempt
- Client was sleeping in the dayroom due to safety precautions. When staff approached to do a safety check, client had 2 socks tied together and was making gestures to put it around their neck. Staff removed the socks and client was assessed. Suicide precautions were extended.
- Licensing follow-up: Licensing viewed camera footage on 11/23/22 and observed 4 residents sleeping in the dayroom due to being on precautions. Due to the camera angle, licensing was only able to observe client’s lower extremities under the covers, moving around on her mattress. No licensing concerns noted.
Police Report
Disorderly Conduct
Caller stated they needed an officer “right now”, stating a client was fighting staff (at approximately 1945 hours). Yelling could be heard in the background of the call. Officers responded to facility. A juvenile was transported to ER after complaining of stomach pain.
Police Report
Extra Patrol
Extra patrol (1839 hours); Complaint only.
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.