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.

Resident reported small abrasion on her palm side next to her thumb from the restraint, petechiae around her eyes and cheeks that were not observed on 10/25/2023. [...] I did not get up as I was eating dinner. [QBHP #1] took her to the seclusion room and called me to take his place. [Client #1] was kicking, screaming, scratching, drew blood from my hand from scratches, and banging her head. [RN #1] brought a pillow.

The Policy "Use of Seclusion-Intensive Residential" (Reviewed 07/24/2023), read in part, "...Seclusion is utilized to protect the patient from injuring self or others...

From the state's report. Deficiency cited, complaint survey. Cited: N 132 PROTECTION OF RESIDENTS N 132; N 172 MONITORING DURING AND AFTER N 172. "[...]" marks text left out between sentences.

In plain words: A child in the program received a head injury during a physical restraint. The facility failed to make sure the restraint did not cause the injury, and the child was sent to the emergency room for a scan. Our summary of the state's report. The state's own wording follows.

Based on record review, the facility failed to ensure a physical restraint did not result in injury for 1 (Client #1) of 1 sampled client who received a head injury during a physical restraint. [...] 6. List any revisions for the resident's plan of care, treatment, or services: Sent to ER [Emergency Room] [Hospital]...Description of injuries: R had silver dollar size hematoma on R [right] lower occipital lobe @ [at] base; Description of Treatment: APRN [Advanced Practice Registered Nurse] notified resident sent to [Hospital] for CT [computed tomography] scan of head..." b.

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

An IR (Incident Report) Narrative dated 10/24/21 documented, "...Time: 03:30 [3:30] PM; Patient Status: Personal Restraint; Intervention Description or Observation Narrative: While staff was performing a restraint pt [patient] began scratching a staff member and head-butting them.

From the state's report. Deficiency cited, complaint survey with poc. Cited: N 132 PROTECTION OF RESIDENTS N 132.

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.

In plain words: The state substantiated a complaint that the facility failed to prevent an injury during a physical restraint. A staff member stated that a nurse failed to have a registered nurse check the injury and did not report it until the next day. Our summary of the state's report. The state's own wording follows.

Complaint #AR00023871 was substantiated, all or in part, with these findings Based on record review and interview the facility Cc 041115 oo 12/10/2019 failed to ensure an injury did not occur during the use of a physical restraint for 1 (Residet #1) of 1 sampled resident who was physically restrained. [...] She stated, "The nurse that was on duty did not get the RN [Registered Nurse] to do a face-to-face and didn't report the injury until the next day..." CFR(s): 483.362(a) Clinical staff trained in the use of emergency safety interventions must be physically present, continually assessing, and monitoring the physical and psychological well-being of the resident and Cc the safe use of restraint throughout the duration of the emergency safety intervention.

From the state's report. Deficiency cited, complaint survey. Cited: N145.. "[...]" marks text left out between sentences.

My therapist was in the hall and called for help. [PT #1] came and put me in a restraint." She was asked, "Did you get injured during the restraint?" She stated, "No." She was asked, "Who was present when this incident occurred?" She stated, "I don't think anyone saw the whole thing, cause she [PT #}) told them to get out of the room." c.

From the state's report. Deficiency cited, complaint survey.

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.

(1719) [5:19 p.m.] pt being sent to ER [emergency room] for evaluation of pain to R shoulder..." d. [...] Then he started to try to count to ten and started to bite one of them and I told him don't bite, don't bite." RN #1 and LPN #1 were asked, "Was he fighting?" LPN #1 stated, "He was trying to come up with his body and his legs were coming out of the restraint, so just kinda wiggle wormed." RN #1 and LPN #1 were asked, "Is bruising normal during a restraint?" LPN #1 stated, "You can get some bruising right there in the crease [indicating crease between the junction of the upper arm and shoulder], that is pretty normal, but not to that extent." Both RN #1 and LPN #1] stated, "Not to that extent." RN #[ and LPN #1 were asked, "Was it caused by undo pressure on his shoulder?" LPN #1 stated, "Yeah, I never seen a restraint look like that." e.

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

The resident was placed into a physical restraint in released from the physical restraint at 8:34 p.m. The form documented a physical assessment was completed by Registered Nurse (RN) #1 on 4/26/19 at 8:34 p.m. The assessment documented Resident #1 had an injury during restraints: "c/o [complained of] left knee pain-good ROM [range of motion] [no] swelling...

From the state's report. Deficiency cited, complaint survey. Cited: N 128 PROTECTION OF RESIDENTS N 128.

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.