| 340:110-3-157(j)(1) | Harmful substances and objects not essential to facility operation are prohibited on the premises. Other poisonous, flammable, or harmful materials are locked when not under adult supervision. | Facility: Razors were left unlocked in the supply closet, allowing residents to have access and self-harm. | Plan of correction received from program as follows: "*3/20/24 RTC Director removed razors from all RTC units and locked them in his office (in a separate building). Requests for razors must be approved by RTC Director. Staff must sign out razors on log sheet & sign back in after use and patients may only use them while supervised. RTC Director shall monitor razor log for compliance daily. *3/20/24 - RTC Director placed signs on supply room doors and re-educated staff to double check doors to ensure locked. *5/15/24 - Director of Facility Ops engaged locksmith to modify locks for auto locking. Parts ordered 5/28. Install ETA depends on part & locksmith availability. Senior leaders shall conduct daily rounds on the RTC units to ensure all doors are locked. 5/27/24 – The RTC Leadership Rounds form was modified to include checking that all supply/utility room and staff office doors are locked. Monitoring of Door locks • Behavioral Health Associates currently conduct environmental rounds every shift. The environmental rounds checklist already includes checking door handles to ensure locked.• Rolling Hills Hospital senior Leaders shall continue to conduct daily rounds on the RTC unit, with emphasis on ensuring that doors to all supply/utility rooms and staff offices are locked." | Substantiated |
| 340:110-3-153.1(b)(4) | Child care personnel. Child care personnel are responsible for meeting residents' needs, taking in account the residents' ages, physical and mental conditions, and other factors affecting the amount of attention indicated. | Additional Non-Compliance Found During Investigation: Personnel: Staff left resident alone for a period of time after finding the resident was self-harming, allowing her to further self-harm. | Plan of correction received from program as follows: "3/26/24 - To optimize staff/patient safety, the ROAR solution was implemented hospital wide. ROAR is a staff alert device (panic button) that each employee wears on their person while working. When an emergent situation occurs, the staff simply presses the fob and an alert for help is sent out throughout the facility. The employee will no longer have to ‘go get help’ as this device makes getting help just a press of a button." | Determined During Course of Investigation |
| 340:110-3-152(f)(1)(F) | a serious resident injury requiring emergency medical treatment by a licensed health care professional; or | Additional Non-Compliance Found During Investigation: Notifications: The program did not notify Licensing of a resident injury requiring emergency medical treatment. | Plan of correction received from program as follows: "The Director of Risk Management self-reported the incident to the Oklahoma DHS Abuse and Neglect Hotline. She had the understanding that DHS Licensing would be automatically notified of her report. Going forward, the Director of Risk Management shall self report all incidents requiring emergency medical treatment to the Oklahoma Abuse and Neglect Hotline as well as to Angela Poyner at DHS Licensing as required." | Determined During Course of Investigation |