Caller reported a juvenile had a vape pen and was vaping on the premises.
Police Report
Disorderly Conduct
PRLU or OLTC
Buildings and Grounds, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 1:55pm – 2:45pm; Census: 31. Walkthrough completed of Blue and Orange Units and outside. Bedroom #103 (Blue) and Bedroom #201 (Orange) was rough around the shower drain and a screw was sticking out around the shower drain in Bedroom #204 (Orange). Maintenance was made aware and stated epoxy would be applied to drain areas.
- TA –
- R910.1 – Disposable cups were observed in the outside play area (removed by maintenance).
- R911.6 – Missing paint was observed throughout Blue and Orange Units (maintenance stated they are getting ready to paint the units).
PRLU or OLTC
Licensing Follow Up, Notice of Incident, Self-Harm
- Licensing (Self-harm)
- Client became dysregulated on unit and charged at peer after a verbal disagreement. Staff intervened and removed peers. Client began throwing chairs and tables, and self-harming using game pieces to rub on her forearm. Client was placed in a restraint after hitting, kicking, and spitting at staff who attempted to get game pieces from client. No injuries were sustained. Client took PRN medication and processed with staff. Client was placed on assault precaution for additional days.
- Licensing follow-up: Specialist was informed by the DON that client did not verbally state she wanted to self-harm. The facility is in violation of their corrective action agreement.
Police Report
Sex Offenses
Juvenile reported a peer raped her at least twice in the last 2 months. Juvenile stated peer “fingered her vagina and anus and performed sex on her.” Juvenile and peer have been separated into different units and will no longer have contact. Upon being interviewed, juvenile stated she did not want to report this and didn’t want peer to get in trouble. Investigator received notes that were reportedly from juvenile to peer, asking peer to rape her and that she needed to do so without notice or warning. The other note was from peer to juvenile, stating she fucked up and the fact that she did not stop when juvenile said stop made it rape. The case will be closed due to juvenile not wanting to press charges and statement she made in the interview contradicts the note she wrote to peer.
PRLU or OLTC
Complaint, Notice of Incident, Visit Compliance Report
- Dual (Complaint)
- Licensing received an email from a former employee, who quit due to a “continuing refusal by upper management to report incidents as required.” Complainant reported a specific incident on 9/25/22, in which a CNA took a resident down to the floor in what appeared to be a “very inappropriate restraint” after being assaulted by resident. The resident and CNA both sustained superficial scratches. After video footage was reviewed, the CEO determined there to be no need to report the incident. Complainant disagreed and submitted a letter of resignation, stating “I could no longer continue in a position I felt was making me compromise my values and fight my superiors almost daily. This has been an on-going issue since day 1.”
- Licensing follow-up: Licensing was informed the CNA involved is no longer employed with facility, and the facility will no longer use Shift Key (an outside contractor). Camera footage was reviewed on 10/03/22 and showed staff out of ratio on the green unit on 9/25/22 (1:10). Staff approached client after client threw crackers at staff, at which point client punched staff. Staff attacked client and placed her arm around client’s neck and slammed her to the ground. Other staff entered unit while staff and client were on the floor. Staff could be seen laying across the client’s mid-section of her body. Referral #2169574 was screened out. Outcome: Founded.
- Licensing cited facility for the following:
- R109.1.g – Staff engaged in unprofessional conduct that can be viewed as physically harmful to a resident.
- R905.9 – Staff did not use the minimal force or time necessary during the restraint hold.
- R907.3 – Staff was out of ratio 10:1 on the green unit.
- R110.9 – Facility failed to report to the child abuse hotline.
- R105.3 – Staff did not receive preservice training before being counted in staff/child ratio.
- R105.7 – Staff participated in a restraint hold of a resident prior to being trained in SAMA.
- R103.1 – Staff did not have all the required background checks conducted before working on the floor with residents.
PRLU or OLTC
Notice of Incident, Sexual Contact
- Dual (Sexual Contact)
- Client made allegation of sexual misconduct involving peer as the initiator. Per client description, this incident took place months ago and there are no recent events to report. Clients were separated and put on different units.
- Child Abuse Hotline was called and accepted. Outcome: Founded. Licensing follow-up: Facility will be cited for R110.12. Licensing complaint is unfounded for any supervision concerns but founded for failing to report the incident to the licensing unit by the next business day (incident occurred on 9/25/22 and was not reported until 10/5/22).
Police Report
Hang Up
Complaint only.
PRLU or OLTC
Corrective Action Visit, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 1130 – 1315. Census: 27. Licensing completed a walkthrough of the Orange and Green Halls, and MARs were reviewed for 5 residents.
- TA –
- R911.6 – Some of the shower floors on the Orange and Green Halls have roughness around the drain. Maintenance was made aware of the licensing concern and agreed to take care of the concern. Licensing will follow-up with the facility on 9/19/22.
PRLU or OLTC
Licensing, Notice of Incident, Suicide Attempt
- Licensing (Suicide Attempt)
- Client became dysregulated due to peers being too loud and tied her shirt around her neck as a ligature. Staff removed the shirt and brought client off the unit to calm down and process with staff. Client was given paper scrubs and will be placed on a 7-day self-harm precaution safety plan with increased line of sight.
- Licensing follow-up: No licensing concerns noted.
Police Report
Hang Up
Dispatch received abandoned 911 call from facility; Upon call back, facility advised there was no emergency.
PRLU or OLTC
Licensing, Notice of Incident, Self-Harm
- Licensing (Self-harm) 1
- Client was self-harming and attempting to assault staff. Client was kicking and punching staff and pulling her hair out. Client was physically restrained and was given an extra dose of her scheduled medications. Client calmed down and processed with staff. Client will be on self-harm and assault precaution safety plan for 7 days.
- Licensing follow-up: Specialist reviewed client’s chart and physician orders on 9/14/22. No licensing concerns noted.
PRLU or OLTC
Licensing Follow Up, Notice of Incident, Self-Harm
- Licensing (Self-harm) 2
- Client was placed in seclusion due to assaulting peers and staff, scratching arms, and pulling out hair. Client calmed down and eventually processed with staff. Client was placed on self-harm and assault safety precautions.
- Licensing follow-up: “See response for Case #009455.”
PRLU or OLTC
Licensing, Notice of Incident, Self-Harm
- Licensing (Self-harm) 1
- Client self-harmed with an unknown plastic object, leaving superficial cuts on her arm. No first aid needed.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Licensing Follow Up, Notice of Incident, Self-Harm
- Licensing (Self-harm) 2
- Client attempted to self-harm with a broken marker. When the marker was removed, client ran to the dayroom and attempted to cut her arm with the metal door frame. When staff went to remove her from the door, a restraint was initiated after client began hitting and biting staff.
- Licensing follow-up: Specialist completed buildings and grounds on 9/14/22 on the Green Hall. It is unknown which metal door frame client attempted to cut her arm on. Specialist observed multiple door frames; The client’s door frame had a rounded strike plate, and the strike plate for the dayroom door frame was square with edges.
PRLU or OLTC
Licensing, Notice of Incident, Self-Harm
- Licensing (Self-harm) 3
- Client self-harmed while in the shower, leaving superficial cuts on her arm. Her arm was cleaned and bandaged.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Licensing, Notice of Incident, Self-Harm
- Licensing (Self-harm) 4
- For the past 3-4 days, client had enormous amounts of reported self-harming, and assaulting staff when trying to keep client safe. Client was given therapy assignments and increased supervision/medications per APRN. Client was placed on assault and self-harm precaution with increased line of sight for the next 7 days due to her behavior.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Licensing, Notice of Incident, Suicide Attempt
- Licensing (Suicide Attempt)
- Client was taken to the comfort room after assaulting staff, where she removed her shirt and attempted to tie it around her neck. The shirt was taken from client and paper scrub was given for her safety. Client was placed on self-harm and assault precautions.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Corrective Action Visit, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Facility visited from 1245 – 1345. Census: 65. Licensing completed a walkthrough of the Blue Unit. The other units (Orange and Green) had residents either being quarantined or positive for Covid-19. Licensing viewed bedrooms and bathrooms for 101 – 105. All shower floors were viewed where epoxy was applied: No sharp edges were noted around the shower drain and no tiles were able to be pulled up from around the drain. No licensing concerns noted.
PRLU or OLTC
Maltreatment, Notice of Incident
- Dual (Maltreatment)
- Report received from another PRTF facility that a client placed in their care disclosed that they had consensual and nonconsensual sexual contact with a female staff member at Perimeter Behavioral of the Ozarks. Dates of sexual contact unknown. Client was placed at facility from 6/9/21 – 3/11/22.
- Licensing follow-up: Specialist spoke to facility and obtained the last name of the alleged offender, and it was determined that the staff has not worked at the facility since 3/11/22. Specialist viewed interview with client and interviewer at Children’s Protection Center. Client denied abuse taking place at any of the placements that she has been a resident and denied reporting any form of abuse to anyone. Licensing complaint is unfounded.
Police Report
Sex Offenses
Juvenile reported that while living at the facility, she had a sexual relationship with a staff member. Juvenile stated they would sneak off to a bedroom and have sex, and stated the sex was consensual at times and at times it was nonconsensual. The alleged staff member no longer works at the facility. Upon being interviewed, juvenile denied anyone at the listed places she has lived has hurt her or touched her.
Police Report
Alarm
Officer responded in reference to alarm; Building secure.
PRLU or OLTC
Complaint Visit, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Licensing observed the following areas: Blue Hall, Green Hall, Orange Hall, classrooms, courtyard, and cafeteria. Green Hall had 6 residents test positive for Covid. The residents are having school in their unit hallway due to Covid. Specialist viewed MARs; No licensing concerns noted.
Police Report
Sex Offenses
Juvenile reported that a staff member allowed her to touch staff’s knee, thigh, and vagina over the clothes. Juvenile stated the incident happened all the time and occurred at the staff’s table in the dayroom. The alleged staff member is no longer employed at the facility. Due to the facility refusing to release the alleged staff member’s name and DOB, police provided a subpoena to facility. The alleged staff member was interviewed, and provided photos of letters and text messages she received from juvenile. Officer sent case forward to Washington County Prosecutors on charges of Sexual Assault 2nd against alleged staff member.
PRLU or OLTC
Maltreatment, Notice of Incident
- Dual (Maltreatment)
- Client reported a staff member allowed her to touch her knee, thigh, and vagina over the clothes. Client reported the incident happened all the time and would occur at the staff’s table in the dayroom. Staff member is no longer employed at facility and was terminated on 6/15/22.
- Licensing follow-up: Specialist was informed by the investigator that the client disclosed another staff member being involved in sexual misconduct. Investigator reported that the facility would not cooperate with identifying the staff member. Specialist contacted the facility and was informed that the staff member was employed from 3/7/22 – 6/15/22. She was terminated on 6/15/22 due to 5 grievances filed. The specialist informed the investigator of this information. Facility cited (R110.13). Outcome: Founded.
PRLU or OLTC
Complaint, Licensing Follow Up, Notice of Incident
- Licensing (Complaint)
- Investigator viewed visible water on the floor of a closet. It was reported the closet appeared to have possible heating and air problems. Staff reported they had just wiped up water with towels; No towels were in sight. The investigator complained of a lack of cooperation from staff when she requested information on a former staff member. The investigator also reported being unable to view camera footage of the reported incident she was investigating.
- Licensing follow-up: Specialist completed a building and grounds and observed Blue Hall, Green Hall, Orange Hall, classrooms, the courtyard, and cafeteria. Green Hall had 6 girls test positive for Covid and are being quarantined; Classes are being held in the unit hallways due to Covid. Specialist viewed MARS. No licensing concerns noted.