Fort Behavioral Health

The operation was out of ratio when two caregivers were left to care for 11 children. The operation continued to be out of ratio when one caregiver was left to care for ten children.

At 17:30, after being injured, a child was observed to bleed from the eye, enough to soak a shirt and cover the floor. The operation did not contact EMS until 17:50

Caregivers did not provide appropriate supervision and environment to children when an acting administrator and supervisor on duty left one caregiver to care for 10 children. Children in care engaged in a physical altercation and the single caregiver was unable to de-escalate the physical altercation and ensure child safety. As a result, one child sustained a significant physical injury. The ratio required at the time of the incident was to be 1 caregiver to every 5 children.

This standard was found deficient as part of a DFPS Investigation.

The operation was out of ratio when a unit of 11 children were left in the care of 2 caregivers, when 3 caregivers were required. One child was indicated to be on one-on-one supervision. The Administrator did not ensure the operation had sufficient staff to care for children in care. An acting administrator left the facility and did not provide a plan to mitigate risk to children while the unit was out of ratio.

Condition #1: Progress reviews for the improvement plan were not available for review. Condition #12: Changes to the personnel file audit were not observed or that the personnel file was still missing the job description, person responsible for the changes, due date, and correction date.

Child in care, with history of self-harming, continue to cut and scratched herself.

Condition #1 - Does not meet Condition #2 - Met Condition #3 - Met Condition #4 - Met Condition #5 - Met Condition #6 - Met Condition #7 - Met Condition #8 - Met Condition #9 - Met Condition #10 - Met Condition #11 - Met Condition #12 - Does Not Meet Condition #13 - Met Condition #14 - Met Condition #15 - Met

4 of 6 child files reviewed had preliminary service plans that were signed outside of 72 hours.

2 of 6 employee files reviewed had suicide prevention training that did not include the number of training hours on the certificates.

Policy and procedures require that only an LVN, RN or medication aide administered medication to children in care. This procedure was not followed.

Non-prescription medication provided to a child in care was not documented on the medication log.

Incident report does not indicate a restraint was used.

Two children at the operation were not supervised in accordance with the information that is described and documented in each child' s individual service plan.

A caregiver failed to provide appropriate supervision which allowed two children to engage in inappropriate contact while on duty at the operation.

Two children in care (15 and 17 years of age) were involved in inappropriate sexualized behavior while placed at the operation, and the caregiver was unaware of the children's activity.

There was a toilet that was clogged and was not in working order.

Serious incident report does not indicate the specific emergency behavior technique.

Children in care were allowed to remain in the same proximity when children were restrained, which resulted in a restrained child being kicked.

5 of 5 child files reviewed did not have TB test results. 1 of 5 employee files did not have TB test results.

Condition #1: Met Condition #2: Met Condition #3: Not Met - 11 out of 30 employees hired or rehired did not have a comprehensive assessement. Condition #4: Met Condition #5: Met Condition #6: Met Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13: Not Met - 5 of 5 service plans audits were missing required documentation. Condition #14: Met Condition #15: Met

5 of 5 child files did not have immunization records.

5 of 5 child files did not have dental visit scheduled.

2 of 5 employee files did not have documentation of education.

Child?s preliminary service plan does not describe how the operation will meet the child?s medical needs or follow-up plan for possible side effects.

Record for daily insulin dosages were not documented in the medication log

Abuse/Neglect investigation reported two staff members did not provide adequate medical care for a child in care.

Child?s preliminary service plan did not include self medication protocols for child and staff members to ensure the child?s health and safety.

Discharge documentation did not discuss when the child was informed of discharge or transfer.

One caregiver was responsible for eight children when a physical altercation broke out between two children in care.

4 of 4 medication logs were missing the medication pill count.

3 of 4 child files reviewed had missing medication dosages.

An employee is present at the operation with an inactive background check status.

Employee who has not completed medication administration training has given medication to a child in care.

Condition # 1: Pending - extention granted to 7/10/23. Condition #2: Met Condition #3: Not Met - operation did not complete a new comprehensive assessment for a rehired employee Condition #4: Met Condition #5: Met Condition #6: Not Met - Employee administered medication before completing medication training requirement per the condition Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13: Not Met - Operation is not completing audit of child files at admission. The operation is not completing audit of children files per the requirement of this condition. Condition #14: Met Condition #15: Not Met - operation did not provide documentation to RCCI in a timely manner. This is in reference to INV#49478617.

4 of 4 mediaction files were missing prescribing health-care professional's name as well as reason for medication.

On June 13th a child was provided a mental health assessment due to a suicide attempt. The child was then hospitalized for treatment. The incident was not reported to Licensing until 3 days later. The incident was not documented as a serious incident.

A child in care was left unsupervised during a one-on-one supervision resulting in suicide attempt.

The operation documents a serious incident report as a incident report.

A child in care attempted suicide and the operation did not document the how the parent was notified.

Youth-in-care did not receive a new Suicide Full Assessment when admitted to care.

In reviewing the admission assessment, youth-in-care assessment of suicide potential was high and intervention plan was not properly implemented.

3 medication files were observed to not have legal guardian signature for psychotrophic medication consent.

Condition #1: The program evaluation submitted is a check list, that provides rating of each criterion. It does not provide information to the reader on how each determination was made. Condition #2: Met Condition #3: Met Condition #4: Met Condition #5: Met Condition #6: Medication policies state a specified person will administer medication, medication file was observed to have multiple nurses administer medication to a child in care. Condition #7: Met Condition #8: Met Condition #9: Met Condition #10: Met Condition #11: Met Condition #12: Met Condition #13:This condition is considered not met because the date of correction is not being documented on the audit form. Condition #14: Met Condition #15: Met

Treatment plans indicated that children must be observed every 15 minutes by staff members. These instructions were not followed.

Clinical Progress Logs documents that children were observed by staff members when they were not.

During sleeping hours, a child in care entered multiple rooms several times without staff's knowledge.

2 service plans reviewed were not completed in 72 hours.

An incident report completed five days after the incident occurred did not include a description of the incident.

The operation failed to notify Licensing within 24 hours of a child in care being transported by EMS for emergent medical care.

A restraint that lasted 3 to 5 minutes was not documented.

3 medication logs show medication was taken without a stated reason.

5 out 15 probation conditions were not met. Condition #1: Met Condition #2: Met Condition #3: Met Condition #4: Met Condition #5: Met Condition #6: Met Condition #7: the training was not due per conditions. Condition #8: Did not meet - trainings not completed with all staff by the due date of 4/12/2023; Condition #9: Did not meet - 18 staff members did not complete trainings by 03/26/2023; Condition #10: Did not meet - 13 staff members trainings were not completed by 3/26/2023; Condition #11: Met Condition #12: Met Condition #13: Met Condition #14: Did not meet - one child file did not have parent notification; Condition #15: Met

5 Medication logs did not have a pill count or inventory listed.

2 service plans reviewed were not completed in 72 hours.

5 Medication logs did not have prescribing doctor listed.

A caregiver failed to abide by a child's supervision requirements which resulted in a suicide attempt.

A child's suicide attempt was not reported as required by minimum standards.

A child placed a bag over the head with the intent to harm himself. The child was not properly assessed for safety after this incident by the operation as required by Minimum Standards.

Child in care was restrained after staff demonstrated behavior that escalated the child. Staff did not engage in appropriate de-escalation techniques.

Children in care were allowed to remain in the same proximity when child restraints were performed.

Staff conducted a restraint of a child where the child was lifted off their feet and taken to the floor. The child sustained an injury to the hand.

A child in care was under the influence of a substance, was behaving abnormally, and was not separated from the group during therapy.

A caregiver implemented a personal restraint, prior to being trained in EBI.

A child in care was placed in a supine restraint for several minutes. There was no indication that this position was the most effective technique.

A restraint was implemented on 02/07/2023. The documentation of the restraint is incongruent with what was observed on the video.

1 of 1 medication log did not provide a reason medication was prescribed.

An admissions assessment completed on 01/21/23 documents that a child was abused. The information was not reported as required.

Operation did not allow children to be interviewed as part of an investigation.

A child was reported absent 3 times to statewide intake. The child's name was not recorded on the unauthorized absence report.

An employee with an inactive background check was on property at the time of the inspection.

A child in care was reported missing on 12/15/22, 12/16/22, and 12/21/22. The child returned after 12/21/22. A trigger review was not completed.

EBI training for SAMA began as of 12/29/22. This technique was not submitted for approval prior to implementation.

The 6 month's unauthorized absence evaluation was requested at inspections conducted on 01/18/23 and 01/24/23. This document was not provided.

Several employee files did not contain verification for how job requirements were met. 1 employee's resume and degree was emailed to support verification after the inspection was complete.

13 employee records did not contain education and/or CPR and First Aid verification as required by the job description.

11 of the 15 records reviewed did not meet the requirement. Specifically, 4 affidavits were incomplete, and 7 affidavits were not notarized or were missing from the record.

Staff members were made inactive as of 12/05/22 and 01/13/23. The reason for their separations was not found in the employee record.

A child placed on 12/02/22 did not have a completed service plan as of inspection date 1/18/23.

2 of the 15 files reviewed did not contain a record of training taken by the employee.

6 caregivers did not have information to support receiving training prior to performing assigned work duties.

A child's record filed a medication log that did not record the reason for the medication, the prescriber's name, or the person who administered the medication.

7 out of 15 employee records were missing job descriptions.

8 of 15 employee files were missing TB exams.

2 of 15 employee records did not have sign statements to abide by this rule.

A care coordinator/caregiver was not involved in the development of 1 child's service plan. The child was not identified to receive treatment services.

A licensed professional was not involved in the development of 1 child's service plan. The child was identified to receive treatment services for emotional disorders.

3 of 15 files did not contain background check request information.

2 nursing staff files did not contain a license.

A caregiver engaged in an inappropriate relationship and did not maintain appropriate boundaries when engaging children in care.

A caregiver solicited images, videos, and encouraged sexualized activities from a 13, 16, and 17 year old children in care.

A child in care used facetime to contact an unknown male often. When the behavior was identified, follow up actions were not implemented to ensure child safety.

The operation did not provide the videos requested by the Investigator pertaining to a particular employee.

Concerns of abuse of a child in care by was not reported within timeframes.

Child was observed to have redness to the armpit area and seen by the facility nurse. The medical encounter was not documented as required on an incident report.

A staff member engaged in tickling, touching, and hugging of children in care without consent. The staff member's actions were indicated to make children uncomfortable.

Multiple staff members were informed of an allegation of a staff member touching children in care and did not report the allegation as required.

Caregivers were notified of allegations regarding staff behaviors that posed a risk to children in care. The staff did not take any action to reduce risk to the children and provide a safe environment.

The service plan for the youth documented a general statement for supervision and did not discuss his employment or the specific needs of the youth.

A youth's job was threatened by a staff member as discipline.

The service plan was not signed by any of the team members.

An employee was named as the Treatment Director for children with Autism Spectrum Disorder. The employee did not meet the requirement of this rule.

A Treatment Director was named as providing services to children with Emotional Disorders. The person identified did not meet the qualifications of this rule.

37 children were in placement. Of the 37 children placed 14 children were receiving services for emotional disorders (38%). At the time of the inspection, the Treatment Directors named did not meet the rule requirement.

The annual log was provided and two children in care who ran away for the facility was not listed.

A contracted mental health professional documented in a child's file that a child was "jumped" by other children in care. The professional described the physical injuries observed. The operation did not report this incident to Regulations.

A child in care was allowed to remain in the same area during an incident involving multiple restraints of another child.

A staff member pushed a child against a wall as a form of discipline.

Two caregivers held a child's arms behind her back as a form of restraint.

A child was restrained multiple times in a day, with 6 or 7 staff members surrounding the child, escalating the situation.

Children in care were allowed to have personal cell phone devices. This process was not according to policy.

The admission assessment did not include the child's legal status.

A group of children were allowed to remain in the same area during a physical incident involving a staff member and another child and a subsequent restraint.

A staff member yelled at a child in care.

A staff member physically fought with a child and had to be held back by another staff to stop the conflict.

There is a video footage of a child leaving the cafeteria to attack another child at the facility. There were two staff standing in the doorway and did not intervene.

There was one bathroom that had a hole in the wall.

The operation has two staff who were shadowing a staff person who did not have current background checks. There were also four employees who were working and had inactive backgeound checks.

Staff interfered with a child's attempt to make a complaint over the phone by not allowing privacy and refusing requests for privacy. Additionally, staff regularly listen to or monitor children's phone calls

A medication was observed stored in a small cup and not in the original container. The medication was not being administered at the time of observation. The medication was originally stored in a blister pack and was left in this cup due to the child refusing to take it in the morning.

Records that were requested during the course of this investigation were not given to RCCR timely. Some documents were requested but not made available to RCCR until another request 13 days later. Additionally records that were requested during an inspection were not provided during the inspection or 2 days later even after an additional request.

A child was not taken to receive medical care twice for severe abdominal pain. Their parent was called to take the child to receive medical care instead.

On 11 of 11 EBI reports reviewed there was no post restraint discussion documented

The preservice is part of orientation.

The operation could not produce EBI documentation from April or May 2022 and reported that they did not keep documentation for EBI that was performed prior to June 2022. Additionally the operation produced 11 EBI reports for June 2022, of which 9 did not include the specific technique of EBI performed, 8 did not include the length of time the EBI was performed for, and 10 did not document when the staff explained the behaviors necessary for the child to be released from a restraint.

The EBI training certificates read that 50% of the training was focused on physical skills training and not 75% focused on techniques for less restrictive interventions

A staff member's training records indicated that they received 37 hours of training in one day.

The supervised experience log documents that the caregiver received 8 hours of "supervised training" on the same date as the training certificates show the caregiver is receiving training. There is no documentation that the caregiver received 40 hours of supervised experience with children in care.

A staff member used physical discipline with a child in care instead of de-escalating, or other more appropriate methods to deal with a conflict.

A staff member hit a child in the chest after the child had a verbal altercation with the staff member.

Three service plans did not have signatures of the child.

The operation had one caregiver for 6 children who were receiving treatment services. During this time a serious incident occurred

Staff admitted to leaving children unsupervised on a couple of occasions when emergencies occurred.

The incident report which documented the restraint did not include he length of time the child was restrained.

Two staff implemented an improper hold by forcibly pushing and restraining a child against the wall.

No effort was made to provide privacy to a child that was restrained by two staff in front of 8 other children.

Two staff performed a restraint on a child for a situation that was not considered an emergency.

The incident reports which documented the restraint did not include the length of time the child was restrained.

A caregiver did not assist a staff member when two youths were involved in an altercation.

A caregiver was informed by 16-year-old and 14-year-old child in care that they were sexually assaulted and the caregiver observed blood on the children(s) clothing. The caregiver then failed to immediately seek medical attention or contact law enforcement as related to the incident.

After receiving two children into care, a staff member took two children to an unauthorized location. She had the children shower after a sexual assault before returning them to the operation. This staff member also allowed one of the children to leave with an unauthorized person.

Two children in care who had a history of sex trafficking and run-away behavior were allowed to go for a walk and eventually ran away.

A staff member did not report a sexual assault of the two children in care. The operation was also informed that 3 staff members' actions may have neglected children in care. The operation did not report any of these incidents to statewide intake.

A staff member failed to seek medical attention for two children in care when they were observed with blood on their clothing and one child was complaining of pain and discomfort.

A child in care did not receive therapy as per service plan. It later lead to the child in care engaging in self harming and destructive behavior.

A preliminary service was not completed for a child in care.

The operation did not have a staff that was able to communicate by using ASL with a child in care that was hearing impaired. Communication devices were taken from a child in care as a form of discipline.

A caregiver did not provide adequate supervision for children in care and was unaware of the ongoing activities that the youth were conducting.

A child in care was restrained longer than one minute.

Two of the CPR certificates reviewed did not have the trainer name, qualifications and the length of hours.

One out of two staff files reviewed did not have first aid training. The staff member received the training for first aid on 8/31/2021. The staff member is current.

There were three rooms with graffiti on the walls.

A caregiver did not demonstrate self-control by having inappropriate sexual conversations, exchanging nude photos, and propositioning to engage in sexual activities with a child in care.

A child did not receive good care and treatment at a facility, when a caregiver was able to use the child's treatment needs to coerce him to engage in inappropriate relations.

A caregiver was providing a child with tobacco products.

Two caregivers were not informed about all of a child's food allergies.

Menus do not document substitutions.

A refridgerator near the serving area in the cafeteria was found to be unplugged and contained a package of spoiled, molded food.

A child with previous aggressive behavior was able to engage in a second altercation with another child in care.

The operation is performing routine searches for residents that require the removal of all clothing.

All children in care are not allowed to shave.

The operation has provided staff with an employee handbook that contradicts their written operational policies, and staff are not consistently following either set of procedures.

All children placed at the operation are restricted from making phone calls for the first seven days without considering the best interest of each child.

A child overdosed on over-the-counter medication and did not receive proper medical attention.

The caregiver informed about the activities the youth were involved in previously did not provide the level of supervision required to ensure children's safety.

The administrator failed to ensure that children in care received appropriate and timely medical care, that staff conducted assigned duties, and ensured the environment was safe for children in care. The operation has had multiple concerns for supervision that have not been addressed in a manner that improves the operation compliance.

A staff failed to provide appropriate supervision and monitor vitals for a 16 year old youth and a 17 year old youth after they ingested several non-prescribed over the counter medications.

Two youths ran away from the operation. There parents were not notified within 6 hours of the youths leaving the operation.

There were multiple restrooms in the boys and girls area that had splattered paint on the walls and the floors. In addition, the restrooms were dirty and had areas that were not clean.

There were several areas of the facility that either had giraffe, holes in the walls and was not clean.

The caregiver did not use good judgment when they did not follow the operations procedures in not allowing children of the opposite sex to be together. This resulted in two children acting inappropriately together.

The assigned caregiver did not provide the level of supervision required to ensure child's safety.

A physician completed exams with youths without having another staff member observing.

A staff member was falsifying documentation concerning visual room checks at night.

A group of children engaged in sexually activity and used unauthorized medication, due to a caregiver not providing the appropriate level of supervision.

The youth were cheeking their medication and not taking it as prescribed when the staff would administer the medication.

The night time visual checks on the children were not being conducted properly by checking on each child in the room.

The Columbia-Suicide Severity Rating Scale measured a child as high risk at admissions. The child and collateral reports disclosed a history of self harm by cutting. The initial service plan does not set a criteria for supervision neither does it implement a safety plan.

A staff member documented that and observation of a child was completed, when it was not done.

A 14 year old, with a history of self harm, was left on the unit without a caregiver. This resulted in the child gaining access to a dangerous object and engaging in self harm. The injuries sustained required medical attention.

Fort Behavioral Health reports that there is no set criteria for monitoring children. Staff are not being designated to complete individualized supervision based on risks identified.

Facility keys were left accessible to children in care. A child used those keys to obtain a razor and then self -harmed.

An employee was working before the initial background check was submitted.

Two children engaged in inappropriate physical contact. The Abuse Hotline was not notified.

Children in care were allowed to have physical inappropriate contact with each other multiple times while being supervised.