OKLAHOMA COMMISSION ON CHILDREN AND YOUTH
OFFICE OF JUVENILE SYSTEM OVERSIGHT
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Report No. COM 10945-19
Date of Issue: February 13, 2020
Report of a Complaint Investigation
Central Oklahoma Juvenile Center
Tecumseh, Oklahoma
Investigation conducted by Harold Jergenson, Oversight Specialist IV, and Raegan Qualls,
Oversight Specialist III
Report written by Raegan Qualls and Harold Jergenson
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Introduction
The Office of Juvenile System Oversight (OJSO) submitted a Confidential Report to the Office of
Juvenile Affairs (OJA) in October 2019. This is the public version of that report.
The OJSO began an unannounced complaint visit on January 9, 2019. The OJSO continued the
complaint visit on January 10, 18, and 24, 2019, and February 21, 2019, at the Central Oklahoma
Juvenile Center (COJC) located in Tecumseh. The OJSO conducted an exit interview with the
facility via telephone on March 27, 2019. A supplemental exit summary was emailed to the facility
on August 8, 2019. The visit was in reference to a complaint received by the OJSO on January 2,
2019, that reported resident KF was found hanging by the neck in the Dorm B bathroom on
Creighton Unit, by other residents housed on the unit. It had been alleged that three Residential
Care Specialists (RCS) on the unit had not properly monitored KF as per facility policy. During the
course of the complaint investigation, it was also alleged that a male staff member had
inappropriate sexual relations with KF and two other residents at the facility, and that KF had been
a victim of bullying by residents on the unit. The facility is a secured rehabilitation program for male
and female juvenile (the females were placed at the facility August 2018) who are adjudicated
Delinquent or Youthful Offender (YO), and in the custody of the Office of Juvenile Affairs (OJA). The
COJC is licensed by the Office of Public Integrity (OPI) Division of OJA for eighty-two beds. The
facility census was sixty on the initial day of the complaint visit (fifty-four males and six females).
All direct quotes used in this report are verbatim.

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1111 North Lee Avenue, Suite 500

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Oklahoma City, Oklahoma 73103

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(405) 606-4900

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(405) 524-0417 fax

 Interviews Conducted

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Entry interview with the interim superintendent, deputy superintendent, interim deputy
superintendent, director of clinical services and systems review coordinator
Three residents
Ten RCS staff
Three clinical staff
Exit conference via telephone with the interim superintendent on March 27, 2019
Supplemental exit summary was emailed on August 8, 2019

Documentation Reviewed

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Census for the facility, including review of the residents’ birthdates and admission dates
Current staff roster
Five resident treatment files
Grievance logs/grievances from August 1, 2018 through January 9, 2019, the OJSO focused on
the grievances that were filed by or on behalf of resident KF (CO-08-094, CO-09-005, CO-10038, CO-11-025 and CO-01-004)
Suicide Tracking Logs from August 1, 2018 through January 9, 2019
Incident Reporting System logs (IRS) from August 1, 2018, through January 23, 2019
Caretaker conduct review (CCR) logs from January 1, 2018 through February 4, 2019
OPI Investigations log from August 1, 2018, through January 9, 2019
Five OPI investigations (three administrative investigations and two criminal investigation
reports) from November 8, 2018, through February 2019 (CO18-10-059, CO18-11-027, CO18-11096, CO18-12-121, and CO19-01-005)
Email from the OJA Advocate General dated December 28, 2018

Findings
Resident Interviews
The OJSO interviewed three female residents. The interview questions pertained to the residents’
perceptions regarding safety, program services, resident’s rights, disciplinary practices, and other
residential program issues. The OJSO noted:
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Three residents reported that they had not witnessed bullying but stated it was “normal girl
drama” and that the girls made up the next day.
Three residents reported that they had witnessed other residents with contraband inside the
facility. Examples from the interviews included pills, and objects that could and were used as
weapons (e.g. glass, screws).
Three residents reported that they had filed several grievances, all reported that the grievance
system does not work, and the majority of the time they never hear from the grievance
coordinator.
Two of the three residents reported that they felt safe sometimes.

No other concerns were noted from the resident interviews.
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 Staff Interviews
The OJSO interviewed ten RCS staff. The interview questions pertained to the staff members’
perceptions regarding resident’s rights, disciplinary policies, and other residential program issues.
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Seven of the ten RCS reported that resident on resident and resident on staff assaults were
commonplace at the facility.
Seven of the ten RCS reported that they had witnessed other residents with contraband inside
the facility (e.g. food, snacks, cell phones, joints, pills, cigarettes).
Seven of the ten RCS reported that they had witnessed residents bullying each other.

Clinical Staff Interviews
The OJSO interviewed three clinical staff members. The interview questions pertained to the
resident treatment files, treatment file documentation, and resident counseling.

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One clinical staff member reported that there was no follow up from a Behavioral Health
Treatment Specialist contracted from the Oklahoma Department of Mental Health and
Substance Abuse Services responsible for entering the data for monthly treatment plan
reviews.

Resident Treatment Files
The OJSO reviewed five resident treatment files. The OJSO noted:
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Five treatment files reviewed did not contain documentation that monthly treatment plan
reviews had been completed from August 2018 through December 2018.

Grievances Log/Grievances
The OJSO reviewed grievances from August 1, 2018 through January 9, 2019. The OJSO focused on
grievances filed by or on behalf of resident KF. A total of five grievances were documented during
the time period reviewed. Four grievances had been filed by KF (CO-08-094, CO-09-005, CO-10038, and CO-11-025) and one grievance had been filed on behalf of KF (CO-01-004 dated January
6, 2019). The OJSO noted:
1.

CO-08-094 dated August 25, 2018: the grievance had a date received stamp of August 28, 2018.
Resident KF stated that the RCS II, “is constantly messing with someone.” KF withdrew the
grievance on September 6, 2018. Grievance resolved September 6, 2018

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Grievance was logged “as received” three days after being filed.
Grievance did not meet the five-day time frame for resolution.

2. CO-09-005 dated August 31, 2018: the grievance had a date received stamp of September 4,
2018. Resident KF stated staff “refused to give me a halo [Handling Alternative Learning
Outlets, H.A.L.O] at 7:53 pm.”

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Grievance was logged “as received” five days after being filed.
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No documentation had been noted of attempts to address this grievance or if KF had been
contacted.

3. CO-10-038 dated October 28, 2018: the grievance had a date received stamp of October 29,
2018. Resident KF stated, “I signed my refocus plan but still haven’t received it. I have to turn it
in by Tuesday, and I don’t have enough time to do it.” The resolution was accepted on
November 1, 2018.

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No concerns were noted from this grievance.

4. CO-11-025 dated October 30, 2018: the grievance had a date received stamp of November 8,
2018. Resident KF reported staff allowed another resident to sleep on the couch, which she
believed showed favoritism. The resolution was accepted on November 9, 2018.

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Grievance was logged “as received” ten days after being filed.
Grievance did not meet the five-day time frame for resolution.

5. CO-01-004 dated January 6, 2019: the grievance had a date received stamp of January 8, 2019.
The grievance stated, “at least 3 residents continuously told RCS…to check on resident KF and
instead of physically checking on her she yelled and after getting no response she just sat back
down and continued to talk about her relationship with her fellow co-workers.” This grievance
had been investigated by OPI (CO19-01-005).

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Grievance was logged “as received” two days after being filed.
Grievance did not meet the five-day time frame for resolution.

No other concerns were noted from the grievances reviewed.
Suicide Tracking Logs
The OJSO reviewed the suicide tracking logs from August 1, 2018 through January 9, 2019. The
OJSO focused only on the times resident KF was placed on Suicide Precaution (SP) and the length
of each incident.

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Resident KF was placed on severe SP on October 31, 2018 at 1449 hours and remained on SP
until November 7, 2018 at 1536 hours.
Resident KF was placed on severe SP on November 11, 2018 at 0848 hours and remained on
SP until November 19, 2018 at 1540 hours.

Incident Reporting System (IRS) Logs
The OJSO reviewed the Incident Reporting System logs from August 1, 2018, through January 21,
2019. The OJSO focused on IRS entries that related to resident KF. There were a total of fourteen
documented incidents directly involving KF during the time period reviewed. Four of these
incidents were investigated by OPI. The OJSO noted:

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 1. CO18-10-041 dated October 14, 2018, 1837 hours. A group of residents were returning to their
unit when three of the residents started running towards the ball field. Resident KF was
assisted onto the roof of the Garren building by one of the other residents. The two remaining
residents were restrained by staff and placed in mechanical restraints almost immediately. KF
remained on the roof until 1918 hours at which time she came down and was placed in
mechanical restraints and escorted to Crisis Management Unit (CMU).
2. CO18-10-059 dated October 15, 2018. This incident was investigated by OPI. See OPI
Administrative Investigation Report.
3. CO18-11-001 dated October 31, 2018, 1444 hours. RCS staff went to check resident KF in her
room. They noted as they approached KF’s room, “…she was at the end of her bunk; she had
pajama pants wrapped around her neck.” As the RCS began to untie the pajamas “…[KF] tried
to fight her telling her to “not touch me”, “let me do this.” Staff called a signal for security
assistance, and KF was escorted to CMU and placed on severe suicide precaution. Staff later
documented, from statements made by KF, she had planned the incident so she could be
placed in CMU with another female resident who had already been placed in CMU.
4. CO18-11-014 dated November 4, 2018. Resident KF picked up a metal object that had fallen on
the floor and gave it to staff.
5. CO18-11-017 dated November 4, 2018, 1901 hours. A Signal 85 [i.e. a call for all available staff
immediate assistance due to an active disturbance] was called to the Lodiska unit due to a
resident on resident assault. When staff arrived multiple residents were assaulting each other
and then began to physically assault staff. As other residents were restrained by staff, resident
KF “…was placed in mechanical restraints…. While [KF] was in mechanical restraints she
began banging her head on the floor in CMU and a signal 60 [i.e. a call for all available staff
assistance due to an escalating situation] was called. A safety helmet was applied to [KF] by
RCS staff.”
6. CO18-11-020 dated November 5, 2018. Resident KF and Resident One would not “follow the
rules of resident restriction.” KF was then escorted to Ross (crisis center).
7. CO18-11-027 dated November 6, 2018. This incident was investigated by OPI. See the OPI
Criminal Investigation Report.
8. CO18-11-042 dated November 9, 2018, 1625 hours. Three residents attempted to AWOL by
jumping a fence and climbing a tree. The residents climbed back down and were escorted to
CMU.
9. CO18-11-046 dated November 11, 2018, 0056 hours. Staff called a Signal 85 due to three
residents “being disruptive after bed time and self harm by minor cutting to the wrists of each.”
The residents said they “have no intentions of serious harm, just a girls pact to show loyalty.”
Resident KF and Resident Two began attacking a female RCS “slamming her head into the
floor multiple times. [KF] kicked her and punched her in on the face….” Staff then placed KF
and Resident Two into mechanical restraints until they had calmed down and then placed them
on close observation to sleep in the dayroom.
10. CO18-11-047 dated November 11, 2018, 0827 hours. Resident KF was on “Suicide Prevention”
due to her actions during CO18-11-046. KF was allowed to use the restroom. When she exited
the restroom at approximately 0832 hours she had a “cross shape cut into the left side of her
face on her cheek.” Two small pieces of glass were collected from KF.
11. CO18-11-052 dated November 12, 2018, 1832 hours. Resident KF and Resident Two entered the
shower at the same time. Staff attempted to separate both residents, at which time, KF and
Resident Two were placed in mechanical restraints and placed in separate cells.

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 12. CO18-11-096 dated November 25, 2018, 2223 hours. This incident was investigated by OPI. See
the OPI Administrative Investigation Report.
13. CO18-12-088 dated December 16, 2018, 2200 hours. Resident KF tripped on her bedroom
drawer, resulting in swelling on her left leg and ankle.
14. CO19-01-005 dated January 1, 2019, 1832 hours. This incident was investigated by OPI. See the
OPI Criminal Investigation Report.
Caretaker Conduct Review (CCR) Log
The OJSO reviewed the CCR log from January 1, 2018 through February 4, 2019. Documentation
recorded a total of thirty-eight CCRs for this period. There were no documented CCR’s that related
to resident KF.
Office of Public Integrity (OPI) Log
The OJSO reviewed the OPI logs from August 1, 2018 through January 9, 2019. The OJSO focused
on OPI investigations related to resident KF. During the time period reviewed a total of five
investigations listed KF as an alleged victim.
OPI Administrative/Criminal Investigation Report
The OJSO reviewed five OPI investigations (three administrative investigations and two criminal
investigations) that related to resident KF which included allegations of inappropriate sexual
contact between residents, lack of supervision, sexual battery/Rape II by staff, failure to provide
heat to the unit, and lack of supervision. The OJSO noted:
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CO18-10-059 “Administrative Investigation” completed on November 8, 2018. The allegations
stated “…on October 15, at approximately 8:16 pm” Resident One made inappropriate sexual
contact with KF and the staff “…did not intervene.” Resident One placed a coat over her and
KF’s lap to cover up what they were doing. It was further reported by Resident Three that “she
found someone had put white cream on her coat….and her clothing was covered in an
unknown substance, which she reported to the staff.”
Resident One had been on Suicide Precaution at the time of this incident, which required the
assigned staff view Resident One’s hands at all times.

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Surveillance video confirmed residents’ inappropriate sexual contact and staffs’ failure to
intervene.

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The allegations of unsatisfactory work performance which allowed two residents to engage
in inappropriate sexual contact was confirmed against staff.

2. CO18-11-027 “Criminal Investigation” was completed on November 9, 2018 and finalized on
February 13, 2019. Resident KF alleged that RCS Six made inappropriate sexual contact with
her “on either 10/31/18 or 11/01/18 while [KF] was at the Crisis Management Unit in Suicide
Precaution.”

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Surveillance video failed to confirm the allegations made by KF.
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The allegations of sexual battery/rape II could not be confirmed due to the surveillance video
not supporting the allegations, lack of physical evidence, and lack of cooperation from the
other persons allegedly involved.

3. CO18-11-096 “Administrative Investigation” dated November 25, 2018, 2223 hours. Two RCSs
work performance was unsatisfactory, for failure to properly monitor Resident One on mild
Suicide Precaution which allowed Resident One to cut on herself. A third RCS work
performance was unsatisfactory for failure to properly monitor Resident One on mild Suicide
Precaution by failing to position themselves so that Resident One’s head and hands were
visible at all times. This incident was discovered when other staff were reviewing surveillance
video at a later time.

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Surveillance video confirmed that the RCSs did not properly supervise Resident One while
on mild Suicide Precautions.

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The allegations of unsatisfactory work performance which allowed Resident One to engage
in self-harming behavior while on mild Suicide Precaution was confirmed on all the RCS
staff.

4. CO18-12-121 “Administrative Investigation” was terminated on January 3, 2019. The allegations
stated “[on] December 22, 2018 at approximately 22:28, There was an incident in which four
residents escaped from Lyda Unit and two of them were able to get on top of Lodiska Unit
destroying the HVAC unit. The next day residents on the unit complained of being cold But
nothing was done by COJC Administrators to rectify the situation like moving the girl’s from
the cold unit to another unit. By 12/28/18 the girls were still on a cold Unit. During the Friday
morning meeting, It was reported that if the weather continues to get cold Administration
would consider moving the girls to another location by lunch time this afternoon as I [the
reporter] was writing this referral the girls had not been moved. This referral is to address the
failure to provide sufficient heat to the girls on Lodiska Unit or mover the residents.” This
investigation was terminated due to the female residents being moved to a different unit with
a working heater.
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The case was terminated due to the residents being moved during the afternoon of
December 28, 2018. The weekly average temperature from December 22, 2018 through
December 28, 2018 was 44 degrees.

5. CO19-01-005 “Criminal Investigation” completed on January 22, 2019. The allegations stated,
“…specifically alleged Caretaker misconduct due to resident [KF]… being left in the bathroom
unsupervised for an extended period of time on January 1st, 2019. During this time, [KF] tied a
sheet around her neck and hung herself from a vent in the bathroom staff on Creighton Unit.
The incident ultimately led to the death of resident [KF] on January 8th, 2019.”
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A written summary of the surveillance video was used as evidence to support the findings
of this investigation.
6:04:05 pm Resident KF entered Dorm B.
6:07:05 pm KF entered into Dorm B bathroom.
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6:08:35 pm RCS Four entered the bathroom.
6:10:10 pm RCS Four exited the bathroom. RCS Five leaned against the staff desk.
6:16:47 pm RCS Five entered Dorm B.
6:17:21 pm RCS Five exited Dorm B, RCS Four is seated at the staff desk.
6:26:34 pm RCS Three entered the unit and relieved RCS Four.
6:28:00 pm RCS Four exited the unit.
6:30:30 pm Three residents entered Dorm B and went into the bathroom.
6:31:00 pm RCS Three and RCS Five entered Dorm B.
6:31:09 pm RCS Three entered the bathroom.
6:31:46 pm RCS Three exited the dorm and used the staff phone.
6:32:12 pm Additional staff arrived.
6:33:23 pm Medical staff arrived on the unit.
6:35:08 pm Staff arrived on the unit with the Automated External Defibrillator (AED).
6:40:22 pm the fire department and Emergency Medical Services (EMS) arrived at the
facility parking lot.
6:42:07 pm The fire department and EMS entered COJC through the rear gate.
6:43:48 pm Two first responders with the fire department arrived on the unit.
6:45:58 pm Residents were moved off of the unit.
6:46:46 pm EMS paramedics arrive on the unit.
7:00:18 pm Paramedics exited the unit with KF on a stretcher.
7:06:50 pm EMS and the fire department left through the rear gate with emergency lights
on.
RCS Five and RCS Four reported that KF had been picked on throughout the day and she
appeared to be sad on the evening of the incident.
Staff interviews reported KF had recently found out that her time at COJC had been
extended for a year.
Resident interviews related KF had been placed on suicide precaution several times.
RCS Five, RCS Four, and RCS Three said KF was often picked on by the other residents.
They believed it occurred because male residents showed an interest in KF and the other
girls were jealous.
The female residents interviewed reported that KF was often picked on by the other
residents with more dominate personalities.
It was reported that the facility allowed co-ed movies, and female and male residents had
been passing notes.
RCS Five reported the ten minute shower rule had seldom been enforced on the girl’s unit.
According to RCS Four and RCS Three, RCS Three had not been informed KF was in the
shower.
Neither the Unit Log nor the Bathroom Log documented that KF was in the shower.
KF entered the bathroom with a folded sheet and her hygiene kit, which had not been
documented as being checked out. The sheet was used by KF to hang herself.
RCS Four stated she had never received training for resident showers.
RCS Four stated that she went into the bathroom to hug KF, and had been in previous
trouble for hugging residents.
Staff at the control center stated that they had never received training on how to contact
emergency services.

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The allegations of unsatisfactory work performance, misconduct, neglect of duty, neglect,
and caretaker misconduct by RCS Four were confirmed.
The allegations of unsatisfactory work performance, misconduct, and neglect of duty, by
RCS Five were confirmed.
The allegation that RCS Three failed to properly supervise KF were not confirmed.
No criminal charges were filed.

Areas of Concern
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Three residents and seven RCSs reported that they had witnessed other residents with
contraband inside the facility. Examples of contraband included pills, and objects that could
and were used as weapons such as glass and screws.
Two residents reported they did not always feel safe.
Seven of the ten RCSs reported that resident-on-resident and resident-on-staff assaults were
commonplace at the facility.
Documents reviewed and resident interviews indicate that residents could easily obtain sharp
objects which they used to harm themselves.
The facility allowed co-ed movies and other co-ed activities, which allegedly caused some of
the “bullying” incidents between the females. When the females were first placed back at
COJC, OCCY had been informed that the males and females would be separated at all times.
Resident KF did not sign into the bathroom on the “Daily Bathroom Log.”
RCS Four stated that she went into the bathroom to hug KF and had been in previous trouble
for hugging residents.
Three residents reported that they had filed several grievances. All reported that the grievance
system does not work and the majority of the time they never hear from the grievance
coordinator.

Violations
1. Four of the five grievances reviewed exceeded the five-day time frame for resolution.
2. One grievance had no documentation that any attempt was made to address the grievance
or contact resident KF.
Policy/Procedure Violated

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OAC 377:3-1-28. General Grievance Procedure, (a), Informal grievances, (5), states “[i]f the
grievance is not resolved within (5) five working days (excluding weekends and holidays),
the juvenile may seek review by the supervisor. (4), The assigned staff shall review each
grievance and attempt to resolve the grievance with the juvenile. If the grievance is not
resolved within (5) five working days (excluding weekends and holidays), the juvenile may
seek review by the supervisor. (6), The supervisor shall have (10) ten working days
(excluding weekends and holidays) from receipt of the review to resolve the grievance.”

3. Seven of the ten RCS staff reported that they had witnessed residents bullying each other.
This is supported by the by the OPI resident interviews for CO19-01-005, that resident KF was
often picked on by the other residents with more dominate personalities.

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 4. Interviews from OPI investigation CO19-01-005 related RCS Five, RCS Four, and RCS Three
informed the investigator resident KF was often picked on by the other residents throughout
the day. They believed it occurred because male residents showed an interest in KF.
Policy/Procedure Violated

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COJC Procedure CO30100.01, Resident Rights, (IV), Protection from Harm, (C), states
“[r]esidents shall not be subjected to corporal or unusual punishment, humiliation, disease,
property damage, mental or personal abuse or harassment, personal injury or punitive
interference with the daily functions of living….”

5. One clinical staff member reported that there was no follow up on a contracted clinical staff
member responsible for entering the data for monthly treatment plan reviews.
Policy/Procedure Violated
• OAC 377:3-13-140. Treatment programs, (e), states “[t]reatment plan reviews shall be
completed and documented on a monthly basis.”
6. Four of the five grievances reviewed were not logged “as received” from two up to ten days
after being filed.
Policy/Procedure Violated

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OJA 377:3-1-28. General Grievance Procedure, (a), Informal grievances, (3), states “[t]he
grievance must be numbered and logged in a grievance log on the day the grievance is
received and distributed to the appropriate staff, excluding a staff member who is the
subject of the grievance, for processing and possible resolution.”

7. Seven of the ten RCS staff reported that they had witnessed residents bullying each other.
This is supported by the female residents interviewed by OPI for CO19-01-005, that resident
KF was often picked by the other residents with more dominate personalities. The OJSO could
not locate any documentation that staff had completed a multipurpose report for these
incidents had been reported.
8. CO18-10-059 documented staff had been informed that a resident’s coat had been “defiled",
but staff “forgot” to report the incident.
9. Interviews from OPI investigation CO19-01-005 related RCS Five, RCS Four, and RCS Three
informed the investigator resident KF had often been picked on by the other residents
throughout the day. They believed it occurred because male residents showed an interest in
KF and the other girls were jealous. The OJSO could not locate any documentation that staff
had completed a multipurpose reports regarding resident KF being “bullied” by other
residents.
10. Documents reviewed (see IRS and OPI reports previous referenced) indicated the female
residents had engaged in inappropriate sexual contact on multiple occasions while staff
looked on.

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 Policy/Procedure Violated

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COJC Post Orders CO20100.14-7, General Duties, states “[r]eport all Major Rule violations to
the supervisor and JSOS on duty. Immediately request a major number from Control,
complete the multipurpose report and request the major to be issues by the JSOS.”

11. CO18-11-096 “Administrative Investigation” dated November 25, 2018, 2223 hours. Two RCSs’
work performance was unsatisfactory, for failure to properly monitor Resident One on mild
suicide precaution, which allowed Resident One to cut on herself. A third RCS work
performance was unsatisfactory for failure to properly monitor Resident One on mild suicide
precaution by positioning themselves where they could not see Resident One’s head or hands
at all times. These allegations did not come from staff working the unit, but when video was
being reviewed for a “Use of Force Briefing” by other staff following the incident.
12. CO18-11-047 dated November 11, 2018, 0827 hours. Resident KF was on “Suicide Prevention”
due to her actions during CO18-11-046. KF was allowed to use the restroom. When she exited
the restroom at approximately 0832 hours she had a “cross shape cut into the left side of her
face on her cheek.” Two small pieces of glass were collected from KF.
Policy/Procedure Violated

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COJC Procedure CO040400.02, Suicide Prevention and Precaution Program, (IV), Placement
of Resident(s) on Suicide Precaution or Prevention, (B), states “[w]hen a resident had been
placed on suicide precaution, the staff will remain within close proximity of the resident and
under continuous visual observation….”
COJC Procedure CO040400.02, Suicide Prevention and Precaution Program, (X), Behavior
Observation Record (BOR) (OJA-ISD-67), (I), states “[s]taff shall ensure that the resident has
NO access to any items that may be used to inflict self-injury…. Pat downs of a resident
may be initiated at any time there is suspicion that the resident may have accessed any
item that could harm them.”
COJC Post Orders CO20100.14-7, General Duties, states “[r]eport all Major Rule violations to
the supervisor and JSOS on duty. Immediately request a major number from Control,
complete the multipurpose report and request the major to be issues by the JSOS.”

13. CO18-12-121 “Administrative Investigation” was terminated on January 3, 2019. The heat and
air unit on Lodiska Unit (female dorm) was destroyed on December 22, 2018. The female
residents had not been moved to a unit with working heat until after December 28, 2018. The
HVAC unit still had not been repaired unit after the New Year. A referral was accepted as an
OPI investigation, but then terminated due to the female residents being moved; however,
according to the National Weather Service the weekly average from December 22, 2018
through December 28, 2018 was 44 degrees.
Policy/Standard Violated

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ACA Standards, 3-JTS-2C-03, Revised January 1991, states “[e]ach sleeping area has at a
minimum, the following facilities and conditions…temperature that are appropriate to the
summer and winter comfort zones.”
ACA Standards, 3-JTS-2D-05, Heating and Cooling, states “[t]emperatures in indoor living
and work areas are appropriate to the summer and winter comfort zones. Comment:

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 Temperature and humidity should be capable of being mechanically raised or lowered to
an acceptable comfort level.”
14. Two of the RCSs interviewed in CO19-01-005 “Criminal Investigation”, reported that resident
KF had recently learned her custody had been extended for another year, the other female
residents had been picking on her throughout the day, and she appeared “sad.” The residents
interviewed and documentation reviewed indicated KF had been placed on suicide precaution
twice for extended periods of time. Given these factor the staff on the unit did not place KF
on “Close Observation.” Instead staff allowed her to take an extended shower, to give her
some alone time.
Policy/Procedure Violated
• COJC Procedure CO040400.02, Suicide Prevention and Precaution Program, (I), Definitions,
states “Close Observation is an increased level of supervision that is used when a resident
has experienced an event in his life that is potentially traumatic or highly stressful and he
needs additional services and support for a period of time.”
• COJC Procedure CO040400.02, Suicide Prevention and Precaution Program, (XV) (4-JCF-4D07M), states “[a]ll staff is trained in the implementation of the ‘Suicide Prevention and
Intervention’ procedure…. At a minimum, the training curriculum will include the following
topics:
A. Identifying the warning signs and symptoms of suicidal behavior.
B. Understanding the demographic and cultural parameters of suicidal behavior,
including incidents and precipitating factors.
C. Responding to suicidal and depressed residents.
D. Improving communications between correctional and health-care personnel.
E. Understanding referral procedures.
F. Understanding any special –housing, resident observations, and suicide watchlevel procedures and requirements.
G. Follow-up monitoring of residents who make suicide attempts
H. Resident suicide research
I. Identification of suicide risk despite the denial of risk….”
15. CO19-01-005 “Criminal Investigation” staff interviews indicated resident KF was allowed to
take a shower because she appeared to be sad. When KF entered the restroom (which was
not documented in the Unit Logs or the Bathroom Logs) she had her hygiene kit and a folded
bed sheet (which she later used to hang herself). It is unclear if KF retrieved her hygiene kit
from her cubical or retrieved it from staff. There was no documentation in the Unit Log Book
or on the Bathroom Log as to where KF obtained her hygiene kit.
16. CO18-10-059 “Administrative Investigation” reported a number of females had access to a
“white cream” substance (from a hygiene box) on the unit with which they “defiled” a
resident’s jacket.
Policy/Procedure Violated
• COJC Procedure CO40200.01, Hygiene and Bathroom Supervision, (II), Hygiene Supplies,
states “[s]upplies necessary for maintaining proper personal hygiene are provided to all
12

 •

residents. Each resident shall be provided soap, toilet paper, a toothbrush, toothpaste,
comb or hairbrush, and special hygiene items for females. (4-JCF-4B-01) Each resident
has a clear plastic storage box to hold his/her hygiene supplies. The boxes are stored in
a central location on the unit and are kept locked when not in use.”
COJC Procedures CO20100.14-7, Post Orders, Youth Guidance Specialist, General Duties,
states “...[e]nsure that daily logbook is up to date and entries are made as needed. Log
the resident census counts, activities, unusual events, incidents, and groups as they
occur.”

17. CO19-01-005 “Criminal Investigation” video revealed at “6:07:05 pm resident KF enters the
bathroom. 6:08:35: pm [RCS Four] enters the bathroom. 6:10:10 pm [RCS Four] exits the
bathroom….6:17:21 pm [RCS Four] is sitting at the staff desk….”
Policy/Procedure Violated

•

COJC Procedures CO20100.14-7, Post Orders, Youth Guidance Specialist, General Duties,
states “[m]aintain constant supervision of residents during all activities and events.
Monitor all bathroom use by standing in a proper location….Staff is to be posted at the
dorm door, any time a resident is in the dorm area, during waking hours including resident
shower time.”

18. CO19-01-005 “Criminal Investigation” video revealed resident KF was alone in the bathroom
for approximately twenty-one minutes without staff supervision. RCS Five reported that the
ten minute shower rule was seldom enforced on the girls unit.
Policy/Procedure Violated
• COJC Procedure CO40200.01, Hygiene and Bathroom Supervision, (I), Bathroom Supervision,
states “... [a]t no time will a resident be allowed more than 10 minutes in the bathroom.
19. According to RCS Four and RCS Three, RCS Three had not been informed that resident KF
was in the shower.
Policy/Procedure Violated
• COJC Post Orders CO20100.14-7, Post Order, Youth Guidance Specialist, General Duties,
states “…[w]hen assuming the post from outgoing YGS, get a verbal shift change report
from the off-going shift, read the logbook for the previous shift, and sign-in the logbook
(signatures from all on-coming staff required), that you have assumed the duty. An entry
will be made in the logbook as to who is responsible for supervision of anyone on suicide
precaution, and anytime a change in supervision is made. When being relieved, give a
verbal briefing to the on-coming shift, and sign-out that you have been relieved, and by
who.”
20. RCS Four stated she had never received training on how to conduct resident showers.

13

 Policy/Procedure Violated

•

COJC Procedure CO20100.07, Resident Supervision,” (VII), Training, states “[t]his procedure
shall be included in new employee orientation and reviewed by supervisors with staff as
changes are made.”

21. Staff working at the control center, on the night of the incident, stated they had never received
training on how to contact emergency services.
Policy/Procedure Violated

•

OJA Procedure CO40300.54-1, states “[d]uring new employee orientation and annually
thereafter, the four (4) minute response policy taught. (ACA 4-JCF-4C-54) This response
time is essential in the event of a health-related incident of serious nature. All saved time
in response is essential to in treating the injury. When a health-care emergency situation
happens, staff on the scene will immediately begin First Aid/CPR if necessary. The staff will
call over their radio ‘Code Blue at (location),’ speaking clearly and repeating the statement
twice. Control will repeat the call twice repeating the location clearly. The control operator
immediately calls 911 and requests emergency response by REACT and the Tecumseh Fire
Rescue. At that point all available staff will respond to the area of the scene. The assigned
JSO will respond to the clinic to assist the nursing staff with emergency equipment.”

14

 Central Oklahoma Juvenile
Center

700 S. 9th Street
Tecumseh Oklahoma 74873

405-598-2130

February 3, 2020
Raegan G. Qualls, M.A.
Oversight Specialist III
Oklahoma Commission on Children and Youth
1111 North Lee Avenue, Suite 500
Oklahoma City, Oklahoma 73103
Ms. Qualls,
Our facility is sending you the attached information as a follow up corrective action plan
response to the findings noted in the Confidential Report sent October 25, 2019.
If you need additional information, please contact the Superintendent’s office at (405) 598-4107.

Dana L. Masquat
Institutional Superintendent

1

 Central Oklahoma Juvenile
Center
700 S. 9th Street
Tecumseh Oklahoma 74873

405-598-2130

TO:

Raegan Qualls, Oversight Specialist III

FROM:

Dana Masquat, Superintendent
Central Oklahoma Juvenile Center

DATE:

November 21, 2019

RE:

Office of Juvenile System Oversight (OJSO)
OCCY Confidential Report Visit 2019

____________________________________________________________________
The following is a response to the areas of concerns and violations noted in the October
25, 2019, memo and report from Raegan G. Qualls, OCCY Oversight Specialist III, in
reference to Confidential Report Visits completed on March 28, April 3, 13, and 25,
2019.
Title of Section: (Areas of Concern)
Concern #1: Three residents and seven Resident Care Specialists report that they had
witnessed other residents with contraband inside the facility. Examples of contraband
include pills, and objects that could and were used as weapons such as glass and
screws.
Response: A memo has been generated requiring all staff to read and sign
acknowledging that they understand that according to COJC Procedure CO20100.06
Facility Access which states that all employees and visitors shall enter the facility
through the Control Center unless the requesting staff member obtains prior written
approval from the Institutional Superintendent/designee. All items brought into the
facility will be searched. Employees may only carry small, clear, see-through bags or
purses, one lip product (lipstick, chap-stick), an umbrella, no more than ten dollars cash,
a lunch container, one comb or brush and eye glasses. Employees are to bring in the
least amount of personal items necessary for their shift. In addition, staff are allowed to
bring in sealed plastic bottled beverages. The Institutional Superintendent/designee is
the only person authorized to make exceptions to this procedure.

2

 Furthermore, all employees/visitors, to include volunteers and mentors, are required to
pass through the metal detector, clear a hand-held metal detector and empty all pockets
prior to entering the facility. All employees/visitors are pat searched. Professional
visitors, i.e. auditors or inspectors, may carry briefcases, but these are inspected prior to
leaving the Control Center.
Furthermore, administration has assigned regular RCS staff to the visitation post and
Central Control. These staff members were trained to monitor and recognize any
unauthorized items.
Concern #2: Two residents reported they did not always feel safe.
Concern #4: Documents reviewed and resident interviews indicated that residents
could easily obtain sharp objects which they used to harm themselves.
Response: It is the practice of this facility to follow the guidelines set forth in the policy
and procedures. Review of the daily security check guidelines are conducted with staff,
to correct future inaccuracies. In the last several months we have increased the amount
of security checks on each shift. We have placed a third staff member on the unit to
increase safety and security. In addition, we have added and relocated camera
locations for more visibility. The pat down procedures on residents have been
increased during transitions to and from locations. There have been safety and security
checks implemented on facility
Procedure:
CO20100.13
Daily Physical Security Inspection, shall be completed by the appropriate security staff
and forwarded at the end of the shift to the Institutional Program Coordinator (IPC)
/designee for review and filing.
Concern # 3: Seven of the ten RCS members reported that resident-on-resident and
resident-on-staff assaults were commonplace at the facility.
Response: The facility’s assaults have drastically decreased over the last year. The
Administration Team has increased RCS staff on the units. There are three staff placed
on the units at all time. This has allowed facility assaults to be reduced significantly. For
example for the month of November 2018 there were 87 Uses of Force, whereas, in
March 2019 there were 14. Staff assaults have also decreased drastically in the past
months, for example in December 2018 there were 28 assaults on staff, whereas, there
were four in March 2019. The Administration team has implemented enhanced training
for the direct care staff, which has assisted in developing effective communication and
de-escalation techniques.
Concern #5: The facility allowed co-ed movies and other co-ed activities which
allegedly caused some of the “bullying” incidents between the females. When the
3

 females were first placed back at COJC, OCCY had been informed that the males and
females would be separated at all times. If the facility were to have present in the
future, considerations will take place to assess the safety and risks of any co-ed
activities. OJA’s Chief Psychologist can help determine if co-ed activities are
appropriate.
Response: There are currently no female residents that meet the requirement of
secure facility placement status.
Concern #6: The said resident did not sign into the bathroom on the “Daily Bathroom
Log”.
Violation #20: The RCS stated she had never received training on how to conduct
resident showers.
Response: Through training and staff development the shower procedures, and
practices have been addressed and revised. On June 6, 2019 a practice memo was
distributed to all COJC staff changing our Standard Operating Procedure for showers.
All staff were instructed of the change and acknowledgment sheets signed. The
changes include having two residents in the restroom at one time with staff in the room
with them to monitor activities, and one staff at the entry to the dorm. It also specified
the exact amount of time given in the shower (5 minutes) as well as at the sink (5
minutes). This also specifies that by staff closely monitoring their time they are
responsible for documenting it as well.
Concern #7: The said RCS stated that she went into the bathroom to hug the said
resident, and had been in previous trouble for hugging residents.
Response: The Office of Juvenile Affairs (OJA) Residential Placement Support (RPS),
Juvenile Program Manual is presented during initial In-Service Training for all new
COJC employees and an acknowledgement for completed by the new employee. A
memo regarding Page 5 of the OJA RPS Juvenile Program Manual outlining
appropriate interactions between staff and juveniles has be issued to all staff to read
and sign acknowledging that they understand. Employee violations of the Juvenile
Program Manual will be handled per OJA Policy 03-05-801 Progressive Discipline. A
memo has been issued referencing the following OJA Policy addressing the appropriate
codes of employee conduct: The said RCS is no longer employed by the Office of
Juvenile Affairs.
Concern #8: Three residents reported that they had filed several grievances. All
reported that the grievance system does not work, and the majority of the time they
never hear from the grievance coordinator.
Violation #1: Four of the five grievances reviewed exceeded the five-day time frame
for resolution.
4

 Violation #2: One grievance had no documentation that any attempt was made to
address the grievance or contact the said resident.
Violation #6: Four of the five grievances reviewed were not logged “as received” from
two up to ten days after being filed.
Response: The grievance procedures have been addressed with department head staff
regarding the grievance resolution timeframe of three working days. Staff has been
instructed to follow policy guidelines and respond to the grievances within the policy
timeframe. CO30100.02 III D. We have increased the level of accountability, and
oversight to ensure grievances are resolved and in a timely manner. We will continue to
strive for excellence in this area
The facilities grievances that were not resolved in a timely manner has drastically
decreased over the last year. For example for the following months:
• December 2018 – 58 grievances filed with 20 unresolved.
• January 2019 – 37 grievances filed with ten unresolved.
• April 2019 – 67 grievances filed with zero unresolved.
• May 2019 – 74 grievances filed with zero unresolved.
• June 2019 – 73 grievances filed with zero unresolved.
• July 2019 – 43 grievances filed with zero unresolved.
• August 2019 – 54 grievances filed with zero unresolved.
• September 2019 – 64 grievance filed with zero unresolved.
Informal grievances CO30100.02
A. Residents shall try to informally resolve a minor grievance by writing a brief description of
the problem and the name of the person or group with whom the resident wants to discuss
the problem. The resident shall write the grievance on Statement of Informal Grievance and
Resolution, form # OJA-AG-2, if possible. The resident shall put the completed form in the
grievance box located on his/her unit.
B. Each day, the Social Services Inspector shall deliver the grievances to the appropriate
staff for resolution.
C. The appropriate staff shall review each informal grievance and coordinate a meeting
between all parties involved.
D. The resident may choose to submit a formal written grievance If the grievance is not
resolved in three working days. The Social Services Inspector shall track the grievance to
ensure compliance with this process.
E. Placement grievances and major grievances may not be resolved informally.
F. The Social Services Inspector shall track and monitor all grievances and forward to the
Institutional Superintendent a copy of this tracking device on a monthly basis.
Violation #3: Seven of the ten RCS staff reported that they had witnessed residents
bullying each other. This is supported by the OPI resident interviews for CO19-01-005, that
said resident was often picked on by other residents with more dominate personalities.
Violation #4: Interviews from OPI investigation CO19-01-005 related that RCS III and RCS
II, and RCS three informed the investigator said resident was often picked on by the other
5

 residents throughout the day. They believed it occurred because male residents showed an
interest in said resident.
Violation #7: Seven of the ten RCS staff reported that they had witnessed residents bulling
each other. This is supported by the female residents interviewed by OPI for CO19-01-005,
that said resident was often picked on by the other residents with more dominate
personalities. The OJSO could not locate any documentation that staff had completed a
multipurpose report for these incidents had been reported.
Response: Immediate response was taken, and several bullying groups were held on
resident units. There has been an increased emphasis placed in the ongoing process
groups and psychoeducational groups. The topic of bullying is within the curriculum utilized
by clinicians and JJSs.
CO20100.04
Daily Shift Report
The Residential Care Specialist Supervisor (RCSS) will complete the Daily Shift Report
form noting any pass- on items, items of concern or caution, security or safety issues. This
form will be forwarded to the Institutional Programs Coordinator (IPC), Institutional Safety
and Security Coordinator (ISSC) or designee for review. (4JCF-2A-10). He/she will compile
and review for completeness and accuracy, all Physical Force reports OJA ISD 31) and
Multi- Purpose Reports and Continuation Reports that are generated during the shift. This
will be completed prior to the end of the shift. (4-JCF-2A-19)
II. Reporting Requirements
Any staff member involved either as a participant or witness to a reportable incident shall
complete a detailed account of the incident on a Multi-Purpose Report, OJA form ISD-32 or
on an IRS Report. Reportable incidents include, but are not limited to: (4-JCF-2A-19) (4JCF-3B-08)
1. State or federal law broken by any person
2. Major rule violations
3. Minor rule violations resulting in CMU admission
4. OJA policy or COJC procedure
5. Injury to a person
6. Property damage
7. Use of force to control juveniles
8. Use of restraint equipment (other than transportation)
10. Important information reported to staff (including rumors)
11. Lost or missing keys
12. Lost or missing tools
III. Required Information – All Multi-Purpose Reports will contain the following:
A. Time and date of the incident;
B. In sequential order, the circumstances preceding the incident and the facts of the
incident;
C. Name of the resident
6

 D. Name of person writing report
E. All persons involved in the incident;
F. Detail the use of force employed;
G. Any rule violation
H. The justification for the use of force, including all efforts taken to avoid the use of force or
the reasons for the lack of such efforts; and
I. Any resulting personal injury or property damage
J. All required signatures.
IV. Additional Pages
A. Staff shall continue writing on Multi-Purpose Report Continuation form # COJC SC-02 if
two pages (front and back of OJA Form ISD-32) are not enough to complete the report.
B. Staff writing the report shall document the additional information on Multi-Purpose Report
Additional form # COJC SC-03 if additional information is requested by reviewing staff.
V. Importance of Content – This is a legal document and may be used in court. Staff shall
describe the details clearly and print so every word is easily read.
VI. Signature and Date – Staff writing the report shall sign and date the report. (4-JCF-2A19) Names shall also be printed below staffs’ signatures.
VII. Routing
A. If the report involves a juvenile, staff writing the report shall submit the completed report
to the RCSS no later than the end of the shift of the staff writing the report.
1. The report will be placed in the resident’s master file after review by by the Institutional
Superintendent/designee (4-JCF-2A-19).
B. If the report does not involve a juvenile, staff writing the report shall submit the original to
the RCSS and a copy to the appropriate supervisor no later than the end of the shift of the
person writing the report.
B. The RCSS IV will review all reports. If there are any incident(s) involving a staff member
in inappropriate behavior/conduct, the RCSS IV will immediately report to the Institutional
Superintendent, Institutional Deputy Superintendent, or Institutional Safety & Security
Coordinator.
C. The Institutional Superintendent shall notify the Institutional Services Division Director.
(4-JCF-3D-01; 4-JCF-3D-02)
Violation #9: Interviews from OPI investigation CO19-01-005 related RCS III, RCS II, and
RCS III informed the investigator said resident had often been picked on by the other
residents throughout the day. They believed it occurred because male residents showed an
interest in said resident, and the other girls were jealous. The OJSO could not locate any
7

 documentation that staff had completed multipurpose reports regarding said resident being
“bullied” by other residents.
Response: Immediate response was taken, and several bullying groups were held on
resident units. There has been an increased emphasis placed in the ongoing process
groups and psychoeducational groups. The topic of bullying is within the curriculum utilized
by clinicians and JJSs.
Violation #11: CO18-11-096 Administrative Investigation dated November 25, 2018, 2223
hours: Two RCSs’ work performance was unsatisfactory, for failure to properly monitor said
resident on mild suicide precaution, which allowed said resident to cut on herself. A third
RCS work performance was unsatisfactory, for failure to properly monitor said resident on
mild suicide precaution by positioning themselves where they could not see said resident’s
head or hands at all times. These allegations did not come from staff working the unit, but
when video was being reviewed for a “Use of Force Briefing” by other staff following the
incident.
Violation #12: CO18-11-047 dated November 11, 2018, 0827 hours: said resident was on
“Suicide Prevention” due to her actions during CO18-11-046. Said resident was allowed to
use the restroom. When she exited the restroom at approximately 0832 hours she had a
“cross shape cut into the left side of her face on her cheek.” Two small pieces of glass were
collected from said resident.

Violation #14: Two of the RCSs interviewed on CO19-01-005, reported that said
resident had recently learned that her custody had been extended for another year, the
other female residents had been picking on her throughout the day, and she appeared
“sad”. The residents interviewed and documentation reviewed indicated said resident
had been placed on suicide precaution twice for extended periods of time. Given these
factors the staff on the unit did not place said on “Close Observation”. Instead staff
allowed her to take an extended shower, to give her some alone time.
Response: There is currently new leadership in place who has identified areas of
concern, and has enforced measures to resolve the Suicide Precaution (SP) procedure.
By April 2019, a new process was developed: it is now the responsibility of the clinician
who is assigned the resident who is placed on status to follow up daily. They are to
ensure that the daily paperwork is being completed. The Clinical Service Director,
Psych Clinician, and Psych Administrative Technician haves developed a quality
assurance tracking system to ensure SP documentation is completed accurately and
thorough, and complete discontinuance of status, and follow up within 72-96 hours of
discontinuance of status. The department supervisor has conducted department
meetings to convey the importance of collecting and maintaining the documentation. A
memo was sent to staff for review and training. They were required to sign
acknowledgment and understanding sheet. This was required to be completed prior to
July 31, 2019; which was successful.
Procedure:
8

 1. CO40400.02 A. Any time a resident makes a suicidal gesture or threat, “any staff’ will
immediately place the resident on suicide precaution, initiate the SPCR form (SPCRISD-63) and will notify the Juvenile Security Officer Supervisor (JSOS). Other reporting
staff will use multi-purpose report (ISD-32). All reports shall be entered into IRS before
the end of shift. The JSOS will immediately make the appropriate notification to other
personnel per the Critical/Major/Significant Incident Notification Check List (Form OJAISD-18).
2. CO40400.02 G. Unit staff and/or Juvenile Security Officers will ensure a pat down
search is completed of the resident. The resident’s room is searched and stripped of any
items considered potentially harmful. The resident’s room will be checked at the
beginning and end of each shift. All personal items will be inventoried, stored on the unit,
issued as needed and returned when the resident is removed from suicide prevention.
Appropriate search forms (Form OJA-ISD-12 and Form OJA-ISD-13) will be completed
and submitted to the JSOS prior to the end of the shift.
3. CO40400.02 K. The Consulting Psychiatrist, Psychological Clinician, or Nurse on Duty
will evaluate the resident activities to determine potential risk factors and document any
changes and reason for changes on the Behavioral Observation Record (BOR). Areas
that may be affected by this may include, but not be limited to:
1. School
2. Skills Center
3. Work assignments
4. Recreational activities
Documentation in the resident’s individualized treatment plan will be made to include
a plan for monitoring, intervention and care and re-evaluation of the resident.
V. B. Staff on each shift responsible for supervision and observation of residents on
suicide prevention will be required to document their review of all relevant suicide
observations and their responsibilities regarding suicide observations (e.g., shower
and bathroom supervision) on the Behavior Observation Record (BOR) ISD-67.
4. CO40400.02 XIII D. A Suicide Tracking Outcome Form (ISD-66) shall be completed by
the psychological clinician regarding the history of the suicide precaution episode,
interventions utilized, results of the BSI and recommendation for follow-up treatment and
concerns and submit to the Psychological Clinician Supervisor for signature. The record
shall be maintained in the resident’s psychological file.
5. CO40400.02 SAME AS LISTED ON #3
6. CO40400.02 IX M. After removal of suicide prevention, the SPCR will be reviewed and
signed by the Unit Manager and forwarded to the assigned Psychological Clinician for
review and completion. The completed SPCR will then be filed in the resident’s
psychological file.
7. CO40400.02 A. Any time a resident makes a suicidal gesture or threat, “any staff’ will
immediately place the resident on suicide precaution, initiate the SPCR form (SPCRISD-63) and will notify the Juvenile Security Officer Supervisor (JSOS). Other reporting
staff will use multi-purpose report (ISD-32). All reports shall be entered into IRS before
the end of shift. The JSOS will immediately make the appropriate notification to other

9

 personnel per the Critical/Major/Significant Incident Notification Check List (Form OJAISD-18).
8. CO40400.02 G. Unit staff and/or Juvenile Security Officers will ensure a pat down
search is completed of the resident. The resident’s room is searched and stripped of any
items considered potentially harmful. The resident’s room will be checked at the
beginning and end of each shift. All personal items will be inventoried, stored on the unit,
issued as needed and returned when the resident is removed from suicide prevention.
Appropriate search forms (Form OJA-ISD-12 and Form OJA-ISD-13) will be completed
and submitted to the JSOS prior to the end of the shift.
9. CO40400.02 K. The Consulting Psychiatrist, Psychological Clinician, or Nurse on Duty
will evaluate the resident activities to determine potential risk factors and document any
changes and reason for changes on the Behavioral Observation Record (BOR). Areas
that may be affected by this may include, but not be limited to:
1. School
2. Skills Center
3. Work assignments
4. Recreational activities
Documentation in the resident’s individualized treatment plan will be made to include
a plan for monitoring, intervention and care and re-evaluation of the resident.
V. B. Staff on each shift responsible for supervision and observation of residents on
suicide prevention will be required to document their review of all relevant suicide
observations and their responsibilities regarding suicide observations (e.g., shower
and bathroom supervision) on the Behavior Observation Record (BOR) ISD-67.
10. CO40400.02 XIII D. A Suicide Tracking Outcome Form (ISD-66) shall be completed by
the psychological clinician regarding the history of the suicide precaution episode,
interventions utilized, results of the BSI and recommendation for follow-up treatment and
concerns and submit to the Psychological Clinician Supervisor for signature. The record
shall be maintained in the resident’s psychological file.
11. CO40400.02 SAME AS LISTED ON #3
12. CO40400.02 IX M. After removal of suicide prevention, the SPCR will be reviewed and
signed by the Unit Manager and forwarded to the assigned Psychological Clinician for
review and completion. The completed SPCR will then be filed in the resident’s
psychological file.

Violation #5: One clinical staff member reported that there was not follow up on a
contracted clinical staff member responsible for entering the data for monthly treatment
plan reviews.
Response: Case Management System Training was conducted on September 16,
2019. A subsequent meeting was conducted on September 24, 2019, with the COJC
Superintendent, JJS Supervisor and Director of Clinical Services in which the
Residential Placement Support’s Deputy Director’s directive was made clear regarding
CMS entries being documented for the 1st of the month through the last day. In the
meeting it was also conveyed via charts and diagrams why these Monthly Treatment
Plan Reviews must be completed by the 10th of the following month in efforts to comply
with OJA policy. All the counseling clinicians, including contracted, have been provided
10

 a calendar of dates when the residents’ monthly treatment plan review is due. The
monthly treatment plan review is discussed in weekly group supervisions.
Violation #13: CO18-12-121, This Administrative Investigations was terminated on
January 3, 2019. The heat and air unit on Lodiska Unit (female dorm) was destroyed on
December 22, 2018. The female residents had not been moved to a unit with working
heat until after December 28, 2018. The HVAC unit still had not been repaired until
after the New Year. A referral was accepted as an OPI investigation, but then
terminated due to the female residents being moved; however, according to the
National Weather Service the weekly average from December 22, 2018, was 44
degrees.
Response: The female residents were moved to Creighton Unit on December 29,
2019. There was partial heat on Lodiska where the female residents were staying from
December 22, 2018 until December 28, 2019. There was controlled temperatures in the
dayroom area; this is where the girls were moved to until further accommodations could
be made.
There were extensive electrical damages on the roof of Lodiska. The
Electrical contractor that was contacted determined that the conduit to each HVAC unit
needed to be replaced, and new wiring ran from the circuit panel to each disconnect. A
light fixture on the west end of the building needed to be replaced, and exhaust fan/duct
work was necessary. Shawnee Electric prepared a quote for repairs, which was
determined to be $4570.00 for the electrical damages. There were three HVAC units
damaged, the cost was $930.00. These repairs were made in January 2019.
Violation #8: CO18-10-059 documented staff had been informed that a resident’s coat
had been “defiled”, but staff “forgot” to report the incident.
Violation #10: Documents reviewed (see IRS and OPI reports outlined in this report)
indicated the female residents had engaged in inappropriate sexual contact on multiple
occasions while staff looked on.

Violation #16: CO18-10-059 reported, a number of females had access to a “white
cream” substance (from a hygiene box) on the unit, “defiled” a resident’s jacket.
Response: The OPI investigation on CO18-10-059 was confirmed on said staff
member for unsatisfactory work performance, reprimanding discipline was imposed on
January 3, 2019.
Violation #15: CO19-01-005 staff interviews indicated said resident was allowed to
take a shower, because she appeared to be sad. When said resident entered the
restroom (which was not documented in the Unit Logs or the Bathroom Logs) she had
her hygiene kit and a folded bed sheet (which she later used to hang herself). It is
unclear if said resident retrieved her hygiene kit from her cubical or retrieved it from
11

 staff. There was no documentation in the Unit Log Book or on the Bathroom Log as to
where said resident obtained her hygiene kit.
Violation #17: CO19-01-005, video reviewed, reveals, “6:07:05 p.m., said resident
enters the bathroom, 6:08:35 p.m., RCS II enters the bathroom. 6:10:10 p.m., RCS II
exits the bathroom…6:17:21 p.m., RCS II is sitting at the desk.
Violation #18: CO19-01-005, video reviewed indicated said resident was alone in the
bathroom for approximately twenty-one minutes without staff supervision. RCS III
reported that the ten minute shower rule was seldom enforced on the girls unit.
Response: The OPI investigation on two employees for neglect was confirmed. Of the
two employees, one had resigned, and the other was terminated.
Violation #19: According to the RCS staff members on duty the RCS III had not been
informed that said resident was in the shower.
Response: This instance was not a change in shifts; this was a change in the staff
member from the RCS II to the RCS III (supervisor) to supervise the shower. Per video
review, the RCS III stands and supervises the shower.
Violation #21: Staff working at the control center, on the night of the incident, stated
they had never received training on how to contact emergency services.
Response: Security has increased the number of Code Blue drills that are conducted
throughout the year. Weekly and monthly security meetings are held to discuss the
behaviors of juveniles, or any special incident that needs to be closely monitored.
When a Code Blue is called, it is now an automatic response that 911 is called by the
control center. When the nurse arrives, they determine the level of severity, the nurse is
provided a phone to confirm or deny the need for the first responders.

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