- ER Visit (Accidental Injury)
- Client taken to ER after sustaining an injury to her knee while attempting to elope from the facility.
- Specialist discussed the event with staff on 3/8/22.
PRLU or OLTC
Notice of Incident
PRLU or OLTC
Notice of Incident
- ER Visit (Seizure)
- Client taken to ER after having a seizure while attempting to elope from the facility.
- Specialist discussed the event with staff on 3/8/22.
Police Report
Alarm
Officer arrived on scene in response to a fire alarm, and was advised that juveniles set off the alarm to escape the facility.
Police Report
Disturbance
Caller (staff) advised dispatch that a juvenile entered the nurse’s station and took items to use as weapons; Caller stated they are understaffed and cannot take care of it. Caller stated a juvenile was hitting a staff member, and juveniles have said “they will beat our ass” and have tried taking keys. Caller does not believe his co-workers are safe. Caller advised that the juveniles were trying to get into the nurse’s station and carrying the base of a punching bag to use as a weapon. Caller heard that a juvenile had been stashing her pills, and a juvenile may have tried to overdose. Caller advised 3 residents escaped by hitting the fire alarm. Caller advised juvenile was having a seizure and another possibly has a broken leg but it is unknown where the juvenile is. Officers located the missing juveniles.
Police Report
Fire
Fire Department required officers on scene while they check a fire alarm and sprinklers.
Police Report
Sex Offenses
On 2/28/22, juvenile disclosed she was being touched inappropriately by an unknown male staff member. Juvenile refused to name the staff member, and later recanted the allegation. Juvenile is being discharged from the facility on 3/7/22 due to an altercation with a peer on 2/27/22. Juvenile was interviewed, in which she did not disclose abuse.
PRLU or OLTC
Notice of Incident
- Complaint
- Specialist was approached by 3 residents during a licensing visit who reported a feeling of being unsafe at the facility. Residents reported that 2 staff members and un unknown staff member have made comments about them in front of other residents to include that they don’t want to work with them or be around them.
- The facility reported that they discussed the concerns with the staff and provided re-education to the staff. Due to there being no evidence to substantiate the claims made against staff, the Licensing complaint is unfounded.
PRLU or OLTC
Visit Compliance Report
- Buildings and grounds walkthrough conducted.
- Regs out of compliance –
- R911.15.f – A ripped up clothing item was found in a bedroom that had been cut, giving it a long strip that could be used as a ligature. Staff removed the threat from the room immediately.
- R912.4 – Several restrooms in the unit bedrooms were seen in poor condition. Restrooms had hair in the sinks, discarded toilet paper on the floors and on the back of toilets. Two toilets (Rooms 204 & 301) had feces sitting in them, clogged, and inoperable. Room 301 toilet was overflowing onto the floor. Room 303 toilet had a small leak around the base with standing water. (Correction Date: 3/1/22)
- R911.6 – Several bedrooms were in disarray. Rooms had clothing on the floor, drink containers, and multiple empty food wrappers. Staff reported the rooms are supposed to be cleaned every morning by residents and staff are supposed to ensure they are clean prior to breakfast. Staff stated they do not believe room checks were conducted for the day. Additionally, the facility reports the agency is in the process of hiring a full-time housekeeper. (Correction Date: 3/1/22)
PRLU or OLTC
Notice of Incident
- ER Visit (Accidental Injury)
- Client slipped in the shower, injuring her right wrist. Client taken to ER. No follow-up details.
PRLU or OLTC
Notice of Incident
- ER Visit (Peer Altercation)
- Client was in altercation with 3 other residents. Client was taken to ER.
- Specialist visited facility on 3/1 and reviewed camera footage. The camera shows 3 residents assaulting client on the ground, but the 2 staff failed to provide the level of supervision and care necessary to ensure the safety of the client. Staff 1 resigned her position on 3/1 and Staff 2 was retrained on appropriate procedures to handle a resident altercation on 2/28 before she returned to work on the unit.
Police Report
Assault
Officer responded to facility for a physical fight in progress; Staff stated there weren’t enough of them on scene to break up the fight. Upon arrival, staff advised officer that juvenile had been attacked by 3 peers after they had been antagonizing her all night and making threats. All 3 peers were issued court dates for Battery 3rd, and juvenile was taken to the hospital (juvenile stated her head and ribs hurt, and someone bit her hand).
PRLU or OLTC
Notice of Incident
- Maltreatment
- A report was made to the Child Abuse Hotline regarding incident in which 2 staff members failed to protect client during an assault by peers.
- Child Abuse Hotline was called and accepted. Staff 1 resigned from her position on 3/1/22; Staff 2 was placed on leave pending results of investigation. Licensing reviewed camera footage on 3/1/22. On 3/8/22, staff stated they were unaware a maltreatment investigation was pending. Staff 2 was allowed to return to work after the incident following retraining, however, on 3/5/22 staff was placed on leave again due to unprofessional conduct. Specialist ensured the agency is aware the staff cannot return to work until the investigation is complete.
PRLU or OLTC
Notice of Incident
- ER Visit (Abdominal Pain)
- Client reported abdominal pain and constipation on 1/18. Laxatives were ordered to be given throughout the day with no success. The client reported continued pain on 1/19 so the client was taken to ER. No follow-up details.
PRLU or OLTC
Personnel Record Review, Visit Compliance Report
- Specialist completed 8 personnel record reviews.
- Regs out of compliance –
- R105.15.c – Staff member (1) does not have verification of his qualifications in his file.
- R105.5 – Staff member (1) does not have verification of CPR/First Aid training.
- R105.4.c – Staff members (2) have no documentation in their charts that they have been trained on the agency’s fire and disaster plans.
- R105.15.h – Staff member (1) only had 1 of her 3 needed personal references.
- R105.4.a – Staff member (1) does not have verification of training on confidentiality in her chart.
- TA –
- R105.10 – Please ensure that training documentation for personnel records dictates what trainings are “psychiatric specific” as standard R105.10 states each child caring staff should complete ten hours of psychiatric specific training before being counted in the child/staff ratio.
- Regs not correctable –
- R103.8 – Seven staff members did not have their initial background checks initiated within 10 days of their hire.
PRLU or OLTC
Notice of Incident
- Complaint
- Licensing Specialist received a complaint called in from a client’s guardian, alleging they believe there are pictures of the child on social media accounts, the facility gave client antibiotics without guardian’s consent, and the client had what the facility reported as “spider bites” all over her (guardian believes to be staph infection).
- Specialist attempted to call the individual who provided the information, but no call was returned. Specialist conducted a visit to facility on 12/20 to review client’s chart, which stated client complained of a single sore on her stomach. The physician was notified and reported it to be a suspected spider bite. Client was prescribed antibiotics and consent was given via telephone by client’s father. Due to no proof of the social media photo, the agency will complete re-training of the social media confidentiality policy with all staff to ensure compliance.
PRLU or OLTC
Visit Compliance Report
- Regs out of compliance –
- R912.4 – Trash in bathrooms, dirty floors and sinks. Please ensure shower curtains are hung up and each bathroom has a trash receptacle that is emptied daily.
- R911.6 – Several bedrooms had excessive amounts of trash. No trash receptacles in bedrooms.
- R913.5 – Please ensure all beds have sheets.
Medicaid Inspection of Care
Inspection of Care Report
- Included: IOC, CAP
- Deficiencies noted. Plan of Correction required to be completed within 30 days.
PRLU or OLTC
Notice of Incident
- ER Visit – Intestinal Blockage
- Resident was experiencing stomach pain for a few days when it suddenly increased on the night of 9/21/21. Client was taken to ER for further evaluation.
- Follow-up 9/22/21: Resident is still currently in the hospital and will be kept overnight again tonight to continue monitor her condition which has been identified as an intestinal blockage.
Police Report
911 Hang Up
911 Hang up from landline; Immediate disconnect. No voices heard. On callback there is no answer at the nurses station. Accidental.
Police Report
Physical Fight in Progress
Caller reported riot was taking place and they do not have the staff to calm everyone down (7 staff members); Fighting at Nurses Station and in the unit. Caller reported there are 2 adults trying to restrain Juvenile. Unknown why they are fighting.
PRLU or OLTC
Notice of Incident
- Arrest
- Resident was acting out trying to hit other residents and staff, pulled down one of the lights on the unit breaking the bulbs from it, and destroyed the door on the fire extinguisher cover. The decision was made to contact the police for further assistance.
- Specialist emailed CEO to determine additional details and staff interventions before police were called. Specialist discussed in emails with CEO details regarding the resident’s discharge and if she was arrested. No video footage of the incident was available.
Police Report
Assault
Caller reported that Juvenile assaulted 3 employees and spit in their faces. No injuries.
PRLU or OLTC
Visit Compliance Report
- Specialist reviewed 8 children’s records and discuss the policies and procedures for the agency that were reviewed.
- Regs out of compliance –
- R102.4 – Agency does not currently have a policy governing the use of cameras for security or surveillance purposes. Please ensure policy includes everything outlined in section R102.4 of the Minimum Licensing Standards. Once the policy has been created/amended it will be provided to the Licensing Specialist for review.
- TA –
- R902.13 – Birth Certificates and social security cards were missing for 4 residents. Immunization records were missing for 4 residents.
- R102.8 – The list of Board of Directors should also include addresses of the board members. A new list of the Board of Directors with their addresses will be provided by 9/9/21.
PRLU or OLTC
Visit Compliance Report
- Specialist viewed full buildings and grounds; Reviewed MARs for 3 residents. Specialist requested policies and will review the documents and ask any additional questions tomorrow during an additional visit to the facility.
- TA –
- R907.3 – Please ensure that if staff is delayed in coming to work or calls in that additional staff are present and have correct training to be counted in the staff/child ratio.
- R911.6 – Specialist discussed the broken or missing tiles located in the showers of some bathrooms of resident rooms. The facility reports there is no plan currently to replace them. Specialist requested the tiles to be repaired or replaced in all residents restrooms that require maintenance.
PRLU or OLTC
Visit Compliance Report
- Specialist discuss incident in which staff pushed resident during an altercation. Specialist reviewed camera footage which shows staff grabbing the resident by the arms and throwing her into a wall forcibly. The resident falls to the ground after hitting her face on the wall. Additional staff can be seen coming into the hallway and standing in the hallway while the resident and staff continued to argue.
- The additional staff member did not report the incident and no other staff were made aware until staff member notified his supervisor. Staff member was placed on administrative leave pending an internal investigation. After video was reviewed, it was decided staff would be terminated.