Severe reports

The report indicated that [Resident 3] contacted the Administrator, [Staff 2], and [Staff 2] directed [Staff 3] to take [Resident 1] to the emergency room for a "rape kit." The incident report further indicates that [Resident 2] and [Resident 3] were the alleged perpetrators of the assault. A review of the discharge paperwork from the hospital confirmed that [Resident 1] was evaluated for sexual assault and had contusions. In an interview over the telephone, [Staff 2] originally reported being unaware that there were any allegations of sexual or physical assault. [...] I need to speak to you asap because apparently a staff member sat and watch this happened and laugh... we really need the cameras." In an interview, [Staff 3] reported that [Staff 5] was the overnight behavioral health technician (BHT) and that [Resident 1] reported that [Staff 5] watched the assaults occur and did not intervene.

In an additional interview over the telephone, [Staff 2] reported never stating being unaware that there were any allegations of sexual or physical assault. [Staff 2] reported being aware only of the physical assault and not the sexual assault.

From the state's report. Deficiency cited, complaint and compliance (annual). Cited: R9-10-711.B.1. Resident Rights B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;; R9-10-716.A.7.b. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: b. Share any space, participate in any activity or .... "[...]" 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.

The document stated, "...Staff informed...[Resident 1] attempted suicide by choking [Resident 1's] self with a shirt to the point [Resident 1] was unconscious [sic] staff immediately called 911. Staff explained that the incident occurred after [Resident 1's] peer was being moved to CRC...[Resident 1] became upset leading [Resident 1] to thoughts about when [Resident 1] would be going home...[Resident 1] went to [Resident 1's] room and shortly after [Resident 1] was found on the floor unconscious with a shirt tight around [Resident 1's] neck. [Police Department] was already on site because of another incident...[Resident 1] was transported to [hospital]...[Resident 1] moved to a higher level of care for now..." 2. [...] The document stated, "...Member attempted to self-harm using a bed sheet to choke [Resident 1's] self. [...] [Staff 7] reported [Staff 1] immediately called 911, removed the shirt, and checked to see if [Resident 1] was breathing. [Staff 7] reported EMS took [Resident 1] to [hospital] and [Resident 1] was transferred to a higher level of care.

From the state's report. Deficiency cited, complaint. Cited: R9-10-716.A.2.b. Behavioral Health Services A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide .... "[...]" 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.

Based on record review, documentation review and interview, the administrator failed to provide written notification to the Department of a resident's self-injury, within two working days after the resident inflicted a self-injury requiring immediate intervention by an emergency medical services provider. [...] 1. A review of [Resident 1]' s medical record revealed an incident report of a medical overdose by [Resident 1] on September 1, 2024. The report stated "At med pass, [Resident 1] was given [Resident 1] seroquel and [Resident 1] took the bottle, emptied it into [Resident 1] mouth, and swallowed 13 or 14 tablets." The report indicated [Staff 4] contacted 911 and poison control, and [Resident 1] was transported and admitted to the hospital. 2. A review of Department documentation revealed documentation to demonstrate BH7513 provided written notification to the Department of [Resident 1]'s self-injury was not available for review.

The assessment stated [Resident 1] is diagnosed with "bipolar disorder", had "3-4 attempts" of suicide, and had "tried to overdose with Benadryl." 4.

From the state's report. Deficiency cited, complaint. Cited: G. An administrator shall provide written notification to the Department of a resident's: 2. Self-injury, within two working days after the resident inflicts a ...; A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity .... "[...]" 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.

In plain words: Medical records showed one child went to the hospital after an injury and was put on meal lockouts and frequent checks. Another child was taken to the emergency room due to self-harm, and the state requested an internal investigation. Our summary of the state's report. The state's own wording follows.

Review of Patient #2's medical record revealed document titled "Unusual Incident/Injury Report" dated February 4, 2024, that revealed various details of the incident and transportation to a hospital via EMS following an assessment by an RN. [...] Staff has been aware of this...and pt was put on 30 minute lockout post meals and pt remains on q5 observation...." Review of Patient #1's medical record revealed "Therapeutic Intervention Note" dated January 11, 2024, that revealed "...Writer assisted BHT in transporting this client to ED...due to client's self harming...." A request was made for an internal investigation conducted by facility, per policies and procedures, for the incident with Patient #1.

From the state's report. Deficiency cited, complaint. Cited: R9-10-303. Administration C. An administrator shall ensure that: 1. Policies and procedures are established, documented, and implemented to protect the health .... "[...]" marks text left out between sentences.

In plain words: An administrator failed to notify the state in writing within one working day about a resident's death from a reported drug overdose. Our summary of the state's report. The state's own wording follows.

Based on documentation review and interview, the administrator failed to provide written notification to the Department of a resident's death, if the resident's death was required to be reported according to A.R.S. § 11-593, within one working day after the resident's death. [...] The e-mail from O1 was dated September 27, 2023 and stated "I received a call from Durango Detention and they informed me a medical examiner [O2] called them and they identified a youth that has an ankle monitor that has been deceased...I asked if [O3] knows what happen and [O3] stated early in the morning, a witness stated [Resident 1] was seen smoking a unknown substance at a QT off [street name] and [Resident 1] was taken to the emergency room where [Resident 1] died of a drug overdose..." 3. A review of Department documentation revealed the administrator failed to provide written notification to the Department of [Resident 1]'s death.

From the state's report. Deficiency cited, complaint. Cited: G. An administrator shall provide written notification to the Department of a resident's: 1. Death, if the resident's death is required to be reported .... "[...]" 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.

In turn, [Resident 1] became intoxicated and had to be transported to the local hospital for assessment. [...] 4. In an interview, [Staff 1] acknowledged, as a result, [Resident 1] ingested alcohol, which caused [Resident 1] to be under the influence, where [Resident 1] was transported to the hospital for a medical assessment.

From the state's report. Deficiency cited, complaint. Cited: A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity .... "[...]" 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.

The report stated [Resident 3] and [Resident 5] appeared to be "under the influence," as staff questioned [Resident 3] and [Resident 5], it was discovered [Resident 3] and [Resident 5] had ingested eight unprescribed Oxcarbazepine 600 mg capsules each, given to [Resident 3] and [Resident 5] by [Resident 2], who had taken the pills during assistance with the self-administration of medication, without staff noticing. Both [Resident 3] and [Resident 5] were transported to the nearest emergency room location in Maricopa.

From the state's report. Deficiency cited, complaint and compliance (annual). Cited: A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings, or equipment or participate in any activity .... 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.