- Licensing Specialist: Kendra Rice.
- Facility visited from 12:30pm – 2pm. Census: 94. Licensing reviewed 3 personnel charts with no licensing concerns noted.
PRLU or OLTC
Personnel Record Review, Visit Compliance Report
Police Report
Noise Complaint
Caller (resident at apartment complex nearby) stated loud music was coming from facility area and was playing “all day yesterday and started up again at noon”. Officers responded, and no excessive noise heard in area. Officer advised caller to call back if noise continues.
PRLU or OLTC
Medical, Notice of Incident
- Licensing (Medical)
- Client’s nose began to bleed while in the cafeteria, and client was taken to the ER due to client’s history of needing a cauterization procedure in the past due to nosebleeds. Client returned from the ER with new orders for a nose spray (no procedures were completed at ER).
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Notice of Incident, Suicide Attempt
- Licensing (Suicide Attempt)
- Client was observed in the bathroom with a bed sheet tied loosely around neck. Client was talking with staff while nurses were able to remove the sheet and process with the client. Client was placed on suicide precautions which includes leaving the door cracked, 6 ft with staff at all times, and sleeping on a cot in the hallway.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Medical, Notice of Incident
- Licensing (Medical)
- Client reported he was having trouble breathing. Client was assessed and the nurse noted client’s vitals were out of range and he had swelling to both hands and his face. Client has a rash that he is currently being treated for with steroids. Client was transported to the ER, and later returned with a new order. Client denied any trouble breathing and the rash was starting to improve.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Medical, Notice of Incident
- Licensing (Medical)
- Client complained of left side abdominal pain, nausea, and vomiting. Client was sent to the ER, and then transferred via ambulance to the Children’s Hospital.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Notice of Incident, Sexual Contact
- Sexual Contact
- Client reported a peer pulled her into the corner of the bedroom and held her with one hand on her chest while she touched client’s genitals both over and under the clothes. Client stated she asked peer to stop, and peer said “I’m not going to stop.” Client was assessed and reported pain and tenderness around the perineum between the labia. Client was provided PRN medication, the therapist on call was notified, and a room change for the peer was implemented.
- Licensing follow-up: Licensing was informed on 10/17/22 that the CACD investigation was unsubstantiated. No licensing concerns noted.
PRLU or OLTC
Licensing, Notice of Incident, Self-Injury
- Licensing (Self-inflicted Injury)
- Client reported pain to his hand after hitting a wall in frustration on 9/16/22. An x-ray was ordered for 9/17/22. Client will visit orthopedic clinic.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Licensing, Notice of Incident, Suicide Attempt
- Licensing (Suicide Attempt)
- Client and peer were observed kissing and were redirected by staff. Client became upset and attempted to tie a shirt around his neck. Staff removed the shirt, and client continued to be combative toward staff and attempted to scratch himself with a staple he found. Client received emergency medication and calmed down. Client was placed on suicide precautions, continuous line of sight, bathroom door cracked and cot in hallway. Referrals were made to acute care on 9/19/22.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Maltreatment, Notice of Incident, Peer Altercation, Visit Compliance Report
- Dual (Maltreatment, Peer Altercation)
- Client had a string of behavioral issues, and staff had to intervene multiple times between client and peer. Client forced his way out of a restraint, and a staff member allegedly hit client on the head. Two staff members confirmed this. Another staff stated the alleged staff member was not attempting to hit client. Staff member was suspended pending the investigation.
- Licensing follow-up: Specialist visited facility on 9/21/22. Resident was interviewed and reported he was placed in a hold against the wall and was hit in the face and stomach by staff. Specialist observed a circular scar on resident’s face that he reported was a bite mark from an altercation with peer. Upon camera review, a different staff member put resident in a restraint than who resident reported. Due to the camera angle, Licensing was not able to view the entire incident. As of 10/17/22, the investigation was completed and the overall finding is unsubstantiated. No licensing concerns noted.
PRLU or OLTC
Complaint Survey with POC, Revisit Survey with POC
- Complaint #AR00028818 was substantiated, all or in part, with deficiencies cited.
- Regs out of compliance –
- N 128 – Failed to ensure a physical restraint did not result in injury for 1 client who received a head injury during a physical restraint.
- N 142 – Failed to ensure an order for a physical and chemical restraint was not received at the same time and failed to ensure a physical restraint was utilized long enough to determine its effectiveness before the administration of a chemical restraint for 1 client.
- N 147 – Failed to ensure the documented times on the Physician’s Order and the time on the ESI Report were the same for 1 client who was placed in a physical restraint.
- N 188 – Failed to ensure all staff involved in an ESI were present at the client debriefing for 1 client.
- N 189 – Failed to ensure all staff involved in an ESI were present at the staff debriefing for 1 client.
- N 207 – Failed to report a serious occurrence to the appropriate agencies for 1 client who received a head injury during a physical restraint.
- Plan of Correction: DON provided counseling and additional education to LPN involved in incident, DON identified 50 ESIs in the past 30 days by record review with any negative findings corrected, DON provided written education to all nursing staff, DON will check ESI documentation the next business day for 8 weeks or until compliance is verified by OLTC.
- A revisit was conducted on 12/14/22 and facility was still not in substantial compliance with the following participation requirements:
- N100 – Failed to meet the Condition of Participation for the Use of Restraint and Seclusion at N100 as evidenced by the facility’s failure to meet the Standard for Protection of Residents at N130 and the Standard of Orders for the Use of Restraint or Seclusion at N140 and N142.N130 – Failed to ensure a client was released from a physical restraint as soon as the emergency situation had resolved for 1 client. Failed to ensure a chemical restraint was not administered after the emergency situation had ended for 1 client.N140 – Failed to ensure an order for seclusion was received for 1 client.N142 – Failed to ensure an order for a physical and chemical restraint was not received at the same time for 1 client and a physical restraint was utilized long enough to determine its effectiveness before the administration of a chemical restraint for 1 client.
- N188 – Failed to ensure all staff who participated in a physical restraint were present at the client debriefing for 1 client.
- Plan of correction: DON identified 48 ESI packets for 11 clients in the past 30 days by record review to ensure clients were not affected. DON provided reeducation, counseling, and additional education to staff. DON will monitor ESI documentation for 8 weeks or until OLTC has verified compliance.
PRLU or OLTC
Accidental Injury, Licensing, Notice of Incident
- Licensing (Accidental Injury 1)
- Client was refusing to go back inside the facility and was restrained after becoming aggressive. A staff member released the restraint sooner than the other staff member, and client fell to the ground and hit her head on the floor. Nurse noted hematoma to the back of her head. Client was taken to the ER.
- Licensing follow-up: Miscommunication between nurse and staff when resident was released from the restraint. Client reported she slipped on her sweatshirt as they were walking through the door. Staff scheduled to complete training on zero tolerance, restraint education, and trauma. Staff submitted a resignation letter, reason unknown. Her last day of employment is 9/21/22.
PRLU or OLTC
Accidental Injury, Licensing, Notice of Incident
- Licensing (Accidental Injury 2)
- On 8/29/22, client was playing basketball and came down wrong on his R ankle. Upon learning of this on 8/30/22, client was assessed. X-ray found no evidence of a fracture or dislocation.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Elopement, Licensing, Notice of Incident
- Licensing (Elopement)
- While outside at 1425 hours, client climbed the pole of the awning and walked the area of the fence, then jumped over the fence. Staff lost sight of client in a wooded area. Police located client at 1930 hours and brought him back to the facility. Nurse assessed client and noted a few abrasions from bushes. Client was placed on elopement precautions, restricted to unit, and will process with his primary therapist.
- Licensing follow-up: No licensing concerns noted.
Police Report
Missing Person
Officers responded for a missing person complaint at approx 2:30pm. Upon arrival, staff stated juvenile jumped over the fence in the playground area and ran down the fence line towards the wooded area. Juvenile was recovered by Johnson PD at approx 7pm, and was taken back to the facility. Fayetteville PD confirmed the juvenile was back at facility.
Police Report
911 Hang Up
Dispatch received 911 hang up. Upon call back, caller stated they were attempting to contact CEMS. No emergency at this time.
PRLU or OLTC
Licensing, Notice of Incident, Self-Injury, Suicide Attempt
- Licensing (Suicide Attempt, Self-inflicted Injury)
- Client began inserting objects into her vagina, then began rubbing her hand on her vagina and smearing the vaginal secretions on staff’s face. Client was also scratching her arm. Client was transported to the ER where the object was removed from her vagina. As client was discharging from the hospital, she attempted to swallow a piece of metal from her face mask. Staff removed it, and she tried to wrap her pants around her neck and verbalized suicidal ideation. Hospital security escorted client outside and refused to let client or staff enter the building. While transporting her back to the facility, client was assaultive to staff and attempted to self-harm. EMS and police were called, and client was transported to another hospital. Client remained there overnight with staff and was accepted into an acute facility for treatment.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Accidental Injury, Licensing, Notice of Incident
- Licensing (Accidental Injury)
- Client’s peer became upset and flipped a table over. The table landed on client’s ankle unintentionally. Client had bruising, slight swelling, and an abrasion to his ankle. X-ray results: No fracture and soft tissue was unremarkable.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Elopement, Notice of Incident
- Elopement
- Client refused to go back inside after the unit was outside and climbed onto an awning on the sidewalk between buildings. Client then jumped on the other side of the fence and off the property. Staff followed client and the police were called. Client was returned to the facility and evaluated; No injuries reported. Client was placed on restriction and re-evaluated in hours, placed on elopement precaution, and followed up with primary therapist.
- Licensing follow-up: No licensing concerns noted.
Police Report
Missing Person
Juvenile left facility with staff following. Juvenile does have wounds on arm from self-harm. An hour later, caller advised juvenile was walked back to facility by staff and had scrapes but was fine and currently talking with the therapist.
PRLU or OLTC
Notice of Incident
- X-ray (Hand Pain)
- Client was evaluated by the APRN after complaining of right-hand pain. X-ray ordered: No fracture or foreign body noted.
- Licensing follow-up: No licensing concerns noted.
PRLU or OLTC
Notice of Incident, Peer Altercation
- X-ray (Peer Altercation)
- Client was hit in the face by a peer; Client’s nose was swollen and bruised upon assessment. APRN was notified and an x-ray was ordered. Diagnosis: Displaced fracture of nasal bone. Client will follow-up with APRN on 8/8/22 for the next step of treatment. Peer was placed on precautions. No follow-up details.
PRLU or OLTC
Complaint Visit, Visit Compliance Report
- Licensing Specialist: Kendra Rice.
- Licensing reviewed resident’s chart and nursing notes. Licensing is not prepared to leave a finding at this time.
PRLU or OLTC
Elopement, Notice of Incident
- Elopement
- While outside processing with their therapist, client ran and jumped over the fence. Staff followed client, and client returned by jumping back over the fence. Client was assessed by nursing staff, and minor scrapes to legs were cleaned. Client was placed on RTU and seen by their therapist.
- Licensing follow-up on 8/1/22: RTU – Restricted on the Unit.
Police Report
Missing Person
Juvenile left facility and said they were going home (Colorado). Juvenile was located on road by facility and was walked back by staff. Juvenile does self-harm and did cut their arm today.