Facility Evaluation Report

On 10/13/23 at 10:40am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an incident which occurred on 8-28-23. LPA met with Administrator Jamesha Boyd and explained the purpose of the visit. LPA reviewed incident report dated 8-28-23 and conducted brief interview with Administrator. According to incident report, on 8-28-23: Resident1(R1) was picked up from day program due to emotional instability and presence of multiple cuts on arm and upper thigh. Based on interview, R1 was not observed to contain cuts prior to attending day program.. Record review and interview revealed R1's cuts were fresh although R1 stated the cuts were made 8-25-23. Administrator arrived to take R1 to mental health. While at acute hospital, R1 eloped and was followed by Administrator until law enforcement arrived to assist. As law enforcement was attempting to assist, R1 became further agitated and began swinging arms prompting law enforcement to place R1 in handcuffs. While R1 was in the back of the police car, R1 began kicking and banging head on the window. Law enforcement brought R1 back to the hospital at which time R1 was placed on a 51/50 hold. While back at the hospital, R1 engaged in additional behaviors of banging head and feet on the walls while attempting to elope. Hospital staff administered medication and evaluated R1. Based on the evaluation, R1 sustained more than 20 cuts on her arms and upper thigh area ranging from 1 to 5 inches in length. According to incident report, physician asked R1 why she cut herself; R1 stated it was due to a breakup with her boyfriend. No medication changes were made at that time.

Incident was reported to licensing within regulatory time frames. Needs and service plan and other documentation was reviewed and updated to reflect new behaviors with interventions in place. Based on interview and record review, R1 has not experienced any similar behavioral episodes and is currently visiting a counselor once per week for additional support initiated by Administrator. Administrator has also initiated additional precautions including securing personal items which may pose a danger including sharp objects. LPA observed R1's room to not contain any dangerous items including sharp objects. As a result of today's case management, no citations are issued. An exit interview was conducted with Jamesha Boyd and a copy of this report was provided to Jamesha.