Disability Rights Arkansas

Perimeter Behavioral of West Memphis / Woodridge of West Memphis

Location: West Memphis, AR

Population Served: Adolescents aging from 12-17 (there is also an Acute onsite for ages 6-17)

# of residents per unit: Up to 18 Residents per room: 3 Capacity: 36

Contact with family (Calls and visit schedule): Family calls 2-3 times per week.

Restraint utilized? Yes Chemical Restraint utilized? Yes Seclusion utilized? Yes

Treatment Components:

Clinical Director - LPC

Therapists: 6 therapists (1 LMSW, 1 LPC, 1 LCSW, 3 MS) that cover the PRTF and 36 bed acute side

Treatment modalities offered: DBT, CBT

# of individual therapy sessions/week: 1-2

# of group therapy sessions led by a licensed mental health professional/week: 3

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PRLU or OLTC

Visit Compliance Report

  • Licensing Specialist: Chelsea Vardell.
  • Facility visited from 12:30 – 14:00. Census: 24. Showers were viewed in all resident bedrooms and no tiles were found to be loose.
  • TA –
    • R911.6 – Please ensure that peeling paint is corrected and repainted throughout each unit.
    • R913.5 – Two resident mattresses on blue unit (102 and 103) and one mattress on orange unit (201) need to be replaced. All resident bedrooms should be checked to ensure that no additional mattresses need to be replaced. 

Police Report

EMS Assist

Staff advised they have a child that is unresponsive, unknown medical history. Transported to ER by EMS.

PRLU or OLTC

Children's Records Review, Visit Compliance Report

  • Licensing Specialist: Chelsea Vardell.
  • Facility visited from 12:40 – 16:00. Census: 18. Children’s record review completed for multiple residents and personnel record viewed for 1 staff member.
  • Regs out of compliance –
    • R902.13 – Multiple residents did not have a copy of their legal documents or documented attempts to receive them from the guardian in the chart within 30 days following admission. Due date: 6/17/22.
  • Regs not correctable –
    • R903.4 – Multiple residents did not have a treatment plan in their chart within 30 days following admission.
    • R103.3 – Staff member is overdue for his child maltreatment registry check. Staff report that the check has now been initiated but is in a pending status.
    • R904.1.p – Multiple residents did not have any individual therapy notes documented within the past 30 days.
    • R105.8 – Staff member did not receive 30 hours of continuing education in 2021.
    • R902.3 – Multiple residents did not have a copy of their immunizations or a documented appointment to receive them within 7 days following admission.
    • R105.13 – Some documentation of annual training was found on a written log in staff members file, but the log did not document the required items listed in the standard.

Police Report

Call Report, Juvenile Complaint

Caller reported juvenile destroying personal property by punching vehicle and leaving a dent. Caller stated juvenile was battering him. Juvenile will be readmitted.

Police Report

Call Report, Runaway

Staff advised at approximately 2:15pm, all juveniles went outside in the back yard for recreational time. Staff stated at approximately 2:35pm, she believes the 2 juveniles ran away from the facility. The 2 technicians supervising the juveniles stated the gate in the backyard was not secured, allowing juveniles to leave on foot. On 4/12 at approximately 11:49pm, J1 was found at a Walmart. He was placed in custody and transported to CCJDC. J2 ran away from officers at Walmart.

Police Report

Call Report, Medical

Juvenile unresponsive, still breathing; History of seizures.

PRLU or OLTC

Background Check Review, Visit Compliance Report

  • Licensing Specialist: Chelsea Vardell.
  • Census on RTC: 18. Visit conducted from 14:00 – 16:30 and from 18:30 – 19:30. MARs reviewed for 4 residents; Background checks reviewed for 25 employees.
  • Regs not correctable –
    • R908.8 – Two medications were not initialed as administered on [date] for one resident.

Police Report

Call Report, Medical

Juvenile hit brick wall, head injury. Juvenile transported by EMS to hospital.

Police Report

Call Report, Fight Call

Manager advised there is a group of females fighting; Parties separated. Unknown if juveniles or staff.

PRLU or OLTC

Personnel Record Review, Visit Compliance Report

  • Specialist reviewed personnel records for 5 staff; Census 21.
  • Regs out of compliance –
    • R105.4.b – Specialist could not locate training verification of resident grievance processes for two staff.
    • R105.15.h – Two staff members only have one of three needed reference checks in their charts.
  • TA –
    • R105.10 – Ensure any training considered psychiatric specific is labeled as such so they can be counted in the required 10 hours of psychiatric specific training required.
  • Regs not correctable –
    • R105.14 – Case manager only completed 2 hours of continuing education for 2020-2021 and 14 hours in 2019-2020.

Police Report

Call Report, Disturbance

Officers responded in reference to verbal altercation; One party went inside the residence, the other stayed outside. No action taken.

Police Report

Alarm - General, Call Report

Accidental; Staff stated a nurse hit the alarm in error.

PRLU or OLTC

Visit Compliance Report

  • Completed buildings/grounds walkthrough, reviewed MARs and 5 children’s records.
  • Regs out of compliance –
    • R914.6 – No escape route diagram located in the educational building; Staff placed a paper copy on the wall until a new plastic copy can be ordered (Corrected on-site).
  • TA –
    • R102.11 – Specialist discussed recent administration changes including a new CEO. Specialist was provided with a new organizational chart. Specialist advised the agency is required to report any changes of Administrator, Social Services Director, or Clinical Director to Licensing within 5 days.

PRLU or OLTC

Visit Compliance Report

  • Specialists conducted unannounced visit, reviewed buildings and grounds with no issues. Reviewed MAR for resident.
  • Regs not correctable –
    • R908.8 – Medication was not documented at time of medical given. Night nurse needs to be retrained on use of MAR and sent to Licensing Specialist when completed. Expected completion date: 10/05/21.

PRLU or OLTC

Notice of Incident

  • ER Visit – Self-Harm 
    • Resident reported to staff on 08/23/21 that she punched a wall on 08/21/21. An assessment was done on her hand and the nurse noted swelling. Resident was taken to ER for further evaluation. No follow-up details.

Police Report

Dispatch Call Detail, Medical

Juvenile having possible seizure, transported Juvenile.

Medicaid Inspection of Care

On-Site Inspection

  • Included: IOC, CAP
  • Multiple deficiencies noted. Plan of Correction required to be completed within 30 days.

Police Report

Information Report

Parent of Juvenile 1 (residing at facility) called stating she was contacted about an incident that took place on the evening of 5/24/21 between Juvenile 1 and Juvenile 2. Juvenile 2 had told Juvenile 1 to sneak out and come to his room that night and he would teach him a “special game” to help him “get over his fears”. Juvenile 1 went to Juvenile 2s room that evening, & once Juvenile 2 explained the “special game” to him, Juvenile 1 told him no several times but eventually gave in. Juvenile 2 turned Juvenile 1 around, pulled his pants down, and rubbed his penis all over his bottom area.

Police Report

Dispatch Call Detail, Juvenile Complaint

Officers made contact with Parent in reference to her juvenile son refusing to exit the car and enter the facility. Parent advised that he is ordered to the facility.

PRLU or OLTC

Visit Compliance Report

  • Regs out of compliance (Reviewed 5 children’s records) –
    • R904.1.h – Resident files for 2 clients do not have copies of legal documents in their files. A copy of their birth certificate, social security card, and immunization records should be placed in the child chart within 30 days after admission or documented attempts to receive them. Due date 6.11.21.
    • R902.2 – There is no medical exam in the chart for client. Due date 6.11.21.

Police Report

Dispatch Call Detail and Incident Report, Runaway

Officers were dispatched to facility in reference to 2 Juvenile runaways. Officers circulated the area with negative results. On 5/8/21 at 2:44 am, Officers were advised that the Marion PD arrested Juvenile 1 and transported him to the Crittenden County Juvenile Detention Facility. On 5/8/21 at 5:22 am, Marion PD advised that Juvenile 2 was located in their city, and was transported to Juvenile Detention.

Police Report

Assist Ambulance, Dispatch Call Detail

CEMS requested assistance with a patient who was irrate; Juvenile was transported to hospital by EMS.

Police Report

Dispatch Call Detail, Request to Speak to Officer

Staff advised Juvenile was being extremely uncooperative and no one feels safe. No police action taken, Officers advised Staff were trying to get in touch with Woodruff County to pick up the Juvenile.

Police Report

Dispatch Call Detail, Request to Speak to Officer

Staff advised Officers of Juvenile on scene causing a disturbance; Parents of Juvenile were trying to drop her off at location and Juvenile refused to go inside. Officers were advised they were able to get Juvenile inside.