Caller reported Juvenile ran away from school and into the woods across the road. Several staff member conducting search. Police arrived; “Clear Alarms” on police report.
Police Report
Runaway Juvenile
PRLU or OLTC
Notice of Incident
- Suicidal
- Client’s peer was having a crisis and client became anxious while inside her room. Client attempted suicide by wrapping her bed sheet around her neck and on her closet rod. Staff intervened and placed client in restraint hold. No injuries noted.
- Client transported to Acute at Pinnacle.
PRLU or OLTC
Notice of Incident
- Suicidal
- Client’s peer was having a crisis and client became anxious while inside her room. Client attempted suicide by wrapping her jacket sleeve around her neck and on her closet rod. Staff intervened and placed client in restraint hold. No injuries noted.
- Client transported to Acute at Methodist.
PRLU or OLTC
Notice of Incident
- Suicidal
- Client’s peer was having a crisis and client became anxious while inside her room. Client attempted self-harm by using plastic hangers to cut her wrist repeatedly. Client then attempted suicide by wrapping her bed sheet around her neck and on her closet rod. Staff intervened and placed client in restraint hold. No injuries noted.
- Client transported to acute care hospital.
PRLU or OLTC
Notice of Incident
- Suicidal/Threatening Behavior
- Client self-harmed by scratching abrasions into her wrists and breaking scabs from previous self-harm areas. Shortly after, client picked up telephone receiver and wrapped the cord around her neck. Staff placed client in restraint for safety and removed telephone cord.
- Specialist made call to facility staff who stated that prior to the phone call, staff had recently had to remove phone cord from client’s neck again today (11/24/21). Staff stated they were actively seeking placement for client in acute facility and if unsuccessful, ACH ER. Staff indicated when alternative placement was found, client would not be allowed to return to facility.
PRLU or OLTC
Notice of Incident
- Suicidal Behavior
- In his therapy session, client reported attempting to electrocute himself by touching wires in the electrical outlet in his room. Client notified staff after receiving a small shock and nurse evaluated and found no injury. Client was placed on increased monitoring and moved to increased viewing room. Client indicated that he wanted to die but had no plan, but the following day stated he did not. No follow-up details.
PRLU or OLTC
Notice of Incident
- Suicidal/Threatening Behavior
- Client became combative, threw a basket, kicked and attempted to punch staff and was then placed in a restraint and locked seclusion. Client started to choke himself with his shirt and staff intervened. Client screamed he wanted to kill himself and banged head on door. Client refused PRN, but eventually calmed down and was allowed to come out of seclusion. No concerns noted by nurse. Specialist left voicemail with facility.
PRLU or OLTC
Complaint Survey
Complaint #AR00027400 and #AR00027434 were unsubstantiated.
PRLU or OLTC
Notice of Incident
- Accidental Injury
- Client injured her knee during game of kickball when a peer slipped and fell on client’s leg. Client was sent to ER and was found to have a sprain of the right knee. Client was given knee immobilizer and will be using crutches. No follow-up details.
Police Report
Medical Emergency
Caller reports subject possibly tore his ACL in field behind admin building. No further info.
PRLU or OLTC
Visit Compliance Report
Visit completed to review video footage of incident. Specialist viewed video of client being escorted into the building by several staff and to the seclusion room. Holds were done appropriately, viewed orders for seclusion and hold. Client was placed on run risk and eyeball precaution status. Staff did everything according to policy and procedures to ensure client safety.
PRLU or OLTC
Notice of Incident
- Accidental Injury
- Client was playing basketball when he fell and heard a pop sound from his leg. Client was taken to ER; No broken bones were found.
- Client should rest and use ice and no physical activity until healed.
PRLU or OLTC
Notice of Incident
- Aggression/Fighting
- Client became escalated after meeting with the nurse, started screaming, and ran out the front door. Client was placed in hold and escorted back to house from school in van by staff. Client was placed in seclusion after continuing to threaten staff/peers. While in seclusion, client wrapped shirt around neck. After shirt was removed, client calmed down and was assessed by nurse. Client had imprint of concrete on forehead, but no laceration. No follow-up details.
PRLU or OLTC
Notice of Incident
- Accidental Injury
- Client was playing football when he collided with another peer and his foot was kicked on accident. Client was advised to get X-ray.
- Specialist emailed facility to find out outcome of ER visit; Facility will get back with specialist after checking with Nursing team.
PRLU or OLTC
Notice of Incident
- Suicide Attempt
- Client was observed with hoodie wrapped around his neck; After staff removed hoodie, client began destroying property and was put in physical hold and placed in seclusion. While in seclusion, client took off his shirt and tried to put it around his neck; Staff removed shirt and administered chemical restraint after client became more calm and stated that he was hungry and wanted to come out to eat dinner.
PRLU or OLTC
Complaint Survey with POC, Revisit Survey
- Complaint #AR00027557 substantiated.
- Regs out of compliance –
- N 132 – Facility failed to ensure a personal restraint was performed in a safe and appropriate manner for 1 client.
- N 189 – Facility failed to ensure a staff debriefing was conducted after the use of a restraint for 1 client.
- N 124 – Facility failed to ensure staff were retrained in the appropriate application of a personal restraint for 1 client who were subject to the inappropriate application of a personal restraint.
- Plan of Correction – A training video was developed to demonstrate appropriate and inappropriate holds; The proper use of a post intervention debriefing is described in a training video that must be completed by staff; All ESIs will be reviewed by the Unit Managers for appropriate use of CPI techniques. All retraining will be reported to the Chief Clinical Officer on a monthly basis. An update to the Ethical Standards Policy #1405 was approved that added duty to intervene for all staff if they observe misconduct.
- During the Revisit Survey conducted on 11/30/21, facility was found to be in compliance with program requirements.
PRLU or OLTC
Notice of Incident
- Medical
- Client was sent to Urgent Care due to eye pain and blurred vision. Client was not able to be seen and was taken to ER.
- Specialist emailed to find out outcome of ER visit; Facility will get back with specialist after checking with Nursing team.
PRLU or OLTC
Notice of Incident
- Aggressive, Threat to Safety, Maltreatment
- Client became escalated and aggressive when his peer laughed at him, resulting in a restraint hold. During hold, client scratched, head butted, bit, and kicked staff members. Client was placed in locked seclusion. After the nurse came to assess, client stated he was choked by staff member during restraint. The nurse found multiple reddened areas around neck. Child Abuse Hotline was called and accepted; Outcome: Exempt.
- 10/27/21 Follow-up: Alleged staff member was terminated by facility. Facility was cited for regulation 905.7.
PRLU or OLTC
Notice of Incident
- Sexual Incident
- Client reported that peer has been sexually inappropriate in general with her over the past few weeks. Client stated the peer has asked her to play strip poker, kissed her, and climbed on top of her in the middle of the night and proceeded to gyrate on her. Client stated she stays awake most nights because she is scared to go to sleep as they are roommates. Child Abuse Hotline was called and accepted.
- CACD gave Specialist permission to contact the agency. Clients are both assigned to separate dorms, classroom, and group sessions. Staff have been informed to keep clients separated during outside time, meal services, and other activities.
Police Report
Runaway Juvenile
Officers responded at approximately 14:08 hours for a Juvenile that ran away from facility into the nearby woods. Officers located Juvenile, and after being resistant, Juvenile was placed in handcuffs. After Juvenile calmed down, handcuffs were removed and he was transported back to facility by staff; Officers followed. Juvenile advised he was mad because he was grounded for not going to bed on time, advised he would calm down.
Police Report
Battery
Staff stated when he spoke to Juvenile about racial slurs and using the N word, Juvenile became upset and ran outside. Staff stated he followed him, and Juvenile picked up a metal pipe and hit staff in the head with it. Officer observed large knot on staff’s head. Officer placed Juvenile in handcuffs. Juvenile was cited, given a court date, and released back to facility care.
PRLU or OLTC
Revisit Survey and Workload Reports, Validation Survey with POC
- Regs out of compliance –
- N209 – Facility failed to ensure the Office of Long-Term Care was notified of a serious occurrence for 1 client who had an injury requiring out of facility medical care.
- Plan of Correction –
- Director of Nursing developed a short training module for all nursing staff that is available on electronic learning system. All nursing staff must complete this module by 10/14/21. An update to facility’s Incident Report Policy #413 was approved on 9/27/21 and includes the instructions for sending incident reports to all regulatory agencies/bodies. The list of serious incidents that have been sent to OLTC will be checked on a monthly basis and reported through the facility’s Performance Improvement Committee.
- Facility was found to be in compliance with program requirements during the Revisit Survey conducted on 10/15/21.
- Survey Team Composition and Workload Report –
- Surveyor 1 onsite 23.5 hours 8am – 6pm; 11.5 travel hours, 1 off-site report prep hours (09/08/21 – 09/14/21).
- Surveyor 2 onsite 23.5 hours 8am – 6pm; 10.50 travel hours, 1 off-site report prep hours (09/08/21 – 09/14/21).
- One surveyor onsite 2.5 hours 8am – 6pm; 2 travel hours, 1 off-site report prep hours (10/15/21).
PRLU or OLTC
Notice of Incident
- Sexual Abuse
- Client was accused of groping 3 peers in inappropriate areas (buttocks, genitals). Peer stated he didn’t inform staff of this when it was occurring because he was “terrified” of client beating him up. Child Abuse Hotline was called and accepted. A member of the AR State Police Crimes Against Children has begun an investigation and will interview residents on 09/14/21.
- On 9/22/21: Facility completed Corrective Action disciplinary for all 3 staff that were working that shift. Had discussion with all 3 staff regarding what was seen on the video and how they could have better supervised the area. Retraining for all staff involved was scheduled for 9/27/21.
- On 9/20/21: Specialist emailed staff for video of incidents to be saved. On 9/29/21, the investigation was still pending.
PRLU or OLTC
Visit Compliance Report
- Specialist viewed video of an incident involving resident; No issues found. Specialist reviewed med logs for 5 residents.
- TA –
- R912.3 – Battery was dead in one of the faucets in the bathroom at Chestnut Hall.
- Regs not correctable –
- R908.8 – Meds for 1 resident were not documented on 8/11/21. This is for a controlled substance.
PRLU or OLTC
Visit Compliance Report
- Specialist conducted building and grounds check on QRTP at Cartwright House. All looked good regarding general safety and the facility appeared to be in full compliance in reference to the building and grounds; Specialist reviewed 4 children’s records with no issues found. Facilities records in great order.
- Regs out of compliance –
- R406.4.d – Ensure all staff are trained in medication documentation. The med logs must contain the initials of the person administering the medication. Compliance date is 8/30/21.