Severe reports

In plain words: A child in the program slammed a bedroom door, and a staff member allegedly followed, screamed and cursed, and shoved the child. Another child reported that the staff member pushed the door open, hitting and hurting the first child's arm. Our summary of the state's report. The state's own wording follows.

Client #3 was sent to the emergency department for an X-ray of the left wrist. [...] Client #3 went into their bedroom and slammed the door, then [Mental health technician 1] came into the room, slammed the door, screamed, "Don't slam this [expletive] door!" Client #3 stated, "I won't slam this [expletive] door in a sassy way." The client reported being shoved into the " cubby " by [Mental health technician 1], and then being put into a PRT and taken out into the hallway. [...] One second later, [Mental health technician 1] was seen aggressively pushing past Client #4 who was standing in the doorway. [...] [Mental health technician 1] reported that she heard small plastic blocks hit the floor. [...] Client #4 reported that Client #3 had gone into the bedroom and slammed the door and was behind the door when [Mental health technician 1] pushed the door open and it hit Client #3 and hurt their arm. [...] Client #3 stated that [Mental health technician 1] came into the bedroom, slammed the door and started screaming and cursing.

From the state's report. Deficiency cited, recertification survey. Cited: N 128 PROTECTION OF RESIDENTS N 128 The Resident affected was assessed by Nursing and. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

At approximately 9:35 AM, via video in hallway footage, two male staff members were seen dragging Client #1 from the seclusion room holding the client under both arms, two female staff members were following.

A review of the emergency safety intervention justification packet dated 08/11/2024 at 1715 [5:15 PM] with a physical and chemical restraint safety intervention implemented revealed Client #3 received an injury due to improper technique of the applied physical restraint. [...] Client #3 during the video review of the emergency safety intervention, it revealed client was pulled from the melee at 5:21 PM and placed into a physical restraint, then received a chemical restraint at Client #3 was interviewed on 8/28/24 1:21 PM and indicated an injury to the right side of the head that occurred during the emergency safety intervention.

From the state's report. Deficiency cited, complaint survey. Cited: N 126 PROTECTION OF RESIDENTS N 126; N 128 PROTECTION OF RESIDENTS N 128. "[...]" marks text left out between sentences.

In plain words: A staff member placed a client in physical, chemical and seclusion restraints after the client became verbally and physically aggressive, kicked doors, tried to leave the building and self‑harmed. The client was injured, receiving bruises, and the incident was recorded in multiple reports. Our summary of the state's report. The state's own wording follows.

restraint/seclusion, not in terms of Based on interview and record review, the facility practicing techniques, but with regard to failed to ensure no injury occurred during a which techniques are approved, when to physical restraint for 3 (Clients #5, #7, and #9) of use restraint/seclusion or not use it 12 (Clients #1-#12) sampled clients who had and the emphasis on avoiding injuries to documented use of restraints and or seclusion. clients and staff and avoiding restraint The findings are: whenever possible. [...] Staff was able to keep client and peer from making it out of the building but client became very physically aggressive with staff, punching them, pushing them, being verbally aggressive. [...] At 1:19:23, the client kicked door and walked down the hallway with four staff following him, pacing with his head down, kicking doors.

Staff pushed, then grabbed the client and drug to the door, then placed Client #7 in a hold at the door. [...] Client and peer used laundry basket to break light covers and used pieces to self-harm with ...1. [...] Client then started kicking doors open in an attempt to elope ...1.

Client then was trying to elope by kicking doors around the unit. [...] Client threw staff phone on the floor and while staff attempted a restraint client hit and grabbed at staff until being place in a restraint." 2.) An Incident Report Packet dated 4/11/21 by BI #4 documented, "...client became verbally aggressive with staff. [...] Once client entered room she began to self-harm.

This will be effective as that caused the injuries and developed and of 9-12-21. implemented a plan to prevent further potential injuries for 1 (Client and #9) 3 (Clients #5, #7 and #9) sampled clients who received an injury during a personal restraint. [...] At 1:19:23, the client kicked a door and walked down the hallway with four staff following him, pacing with his head down, kicking doors. [...] On 8/13/21, at 9:05 a.m., Registered Nurse (RN) #2 was asked, "How did [Client #9] get injured during a restraint on 7/27?" She stated, "He's a very aggressive, big child. He was attacking staff, and staff had to put him in a restraint, and he was taken to the floor and he got bruising.

A Seclusion and Restraint Form dated 4/12/21, documented, "Date and Time Initiated; 4/12/2021 7:21 AM; Date and Time Ended: 4/12/21 8:20 AM...Behavior demonstrated to justify use of procedure: Physically and verbally aggressive with staff, kicking doors, attempting to elope, property damage...Beginning Time: 7:23 AM; Procedure: Seclusion...Client Behavior: Combative, Cursing...Beginning Time : 7:32 AM; Procedure: Chemical Restraint; Location: Seclusion Room;...Client Behavior: Cursing..." A Report To Quality Assurance dated 4/12/21 documented, "...he began kicking doors and being non-compliant, client was asked by staff to stop but he continued until he kicked and broke one of the doors, the nurse was notified and from there client was placed in seclusion and given a chemical..." A Behavioral Intervention Observation Log dated 4/12/21 documented, "...Time 7:23 am; Procedure: 3 (Seclusion); ...Client Behavior: 2 (Calm)...Time: 7:32 am; Procedure: 4 (Chemical);...Client Behavior: 2...Time: 7:33 am; Procedure: 4...Client Behavior: 2...Time: 7:48; Procedure: 3 (Seclusion)...Client Behavior: 2...Time 8:03 am; Procedure: 3...Client Behavior: 2...8:03 am; Procedure: 3...Client Behavior: 2...8:18 am; Procedure: 3...Client Behavior: 2...8:20 am; Procedure: 3...Client Behavior: 2...release from procedure ...." Documentation indicated the client was calm at the time he was placed in seclusion, was calm at the time of the administration of the chemical restraint in the seclusion room and remained calm for 57 minutes before he was released. b.

A Seclusion and Restraint Form dated 6/21/21 documented, "...Aggressive with staff and kicking open unit doors attempting to elope... [...] Self-Inflicted... [...] The Seclusion and Restraint form dated 5/12/21 at 10:02 a.m. documented, "...kicking unit doors, self-harming, physically aggressive with staff..." RN #2 was documented as participating in the ESI for Client #3 but was not listed as participating in the Client Debriefing.

From the state's report. Deficiency cited, complaint survey with poc. Cited: N 128 PROTECTION OF RESIDENTS N 128; N 140 ORDERS FOR USE OF RESTRAINT OR N 140 Upon review of these identified issues, it is; N 149 ORDERS FOR USE OF RESTRAINT OR N 149; N 202 MEDICAL TREATMENT FOR INJURIES N 202 This deficiency has the potential to impact 9-15-21; N 130 PROTECTION OF RESIDENTS N 130 This deficiency has the potential to impact; N 188 POST INTERVENTION DEBRIEFINGS N 188 This deficiency has the potential to impact 9-15-21. "[...]" marks text left out between sentences.

Then [Staff #8] is pushing my arm against the ground, pushing wrist down, pushing my elbow up.

From the state's report. Deficiency cited, complaint survey with poc. Cited: N 128 PROTECTION OF RESIDENTS N 128; N 202 MEDICAL TREATMENT FOR INJURIES N 202; N 214 EDUCATION AND TRAINING N 214.

He released the resident with excessive force.

From the state's report. Deficiency cited, complaint survey with poc. Cited: N 126 PROTECTION OF RESIDENTS N 126; N 216 EDUCATION AND TRAINING N 216.

Staff intervened and resident then began slapping, punching, and kicking at staff when redirecting resident out from under the peer's bed.

From the state's report. Deficiency cited, complaint survey with poc. Cited: N 126 PROTECTION OF RESIDENTS N 126.

Resident was throwing cups on the unit which upset one of his peer to where resident tried to fight the peer but staff intervene and got hit by resident. [...] Resident began to hit and kick staff spitting and scratching at staff when they blocked his blows, kicking in restraint repeatedly. [...] Resident attacked peers and staff, punching, hitting and kicking. [...] Resident Behavior ... [Resident] fighting with staff in restraint, shoving, kicking, biting and scratching in restraint ..." This progress note was signed by the physician on 9/22/19 at 10:00 a.m. 7.

From the state's report. Deficiency cited, complaint survey with poc. Cited: N 131 PROTECTION OF RESIDENTS N 131. "[...]" marks text left out between sentences.

The facility failed to meet the regulatory requirements for Protection of Residents at N128, as evidenced by the facility's failure to ensure Resident #1 was freé from injury during a restraint. [...] Restraints: All staff will receive immediate training following a restraint where the resident being restrained makes an allegation of the use of an inappropriate restraint. d. [...] Client #1 was asked, "Were you injured during the restraint?" The client stated, "Yeah, there was a knot behind my ear... [...] Restraints: All staff will receive immediate training following a restraint where the resident being restrained makes an allegation of the use of an inappropriate restraint. d. [...] Restraints: All staff will receive immediate training following a restraint where the resident being restrained makes an allegation of the use of an inappropriate restraint. d.

From the state's report. Deficiency cited, complaint survey. "[...]" marks text left out between sentences.