**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record and document review, the facility failed to protect the rights of two Resident's (R )1 and R2 to be free from abuse. R1 suffered physical injuries on 06/11/2024 when a Certified Nurse Assistant (CNA)1 did not react and respond appropriately to R1's aggressive behavior. CNA1 did not leave the room, but willfully continued to interact and react with unnecessary physical contact which resulted in R1 suffering harm. R1 had bruising to the Left (L) forehead, L temple and scratch type injury to his chest. The injuries are not justifiably explained. In addition, on 08/10/2024, staff witnessed non-consensual sexual contact when R3 was observed with his hand inside R2's blouse. R2 does not have the capacity to consent. These incidents occurred in the past, and the facility was in substantial compliance with the regulation at the time of this survey and this citation met the criteria for past noncompliance. Findings include: 1) R1 is an [AGE] year-old male has been a resident at the facility since 05/13/2022. He was admitted after a prolonged stay at an acute care hospital. His medical history includes, dementia, chronic urinary retention with a chronic indwelling catheter, bipolar disorder, and depression. R1 needs assistance with activities of daily living and had been one person assist for transfers. He prefers to spend most of the time in bed and has a history of refusing care. On 02/09/2024, his BIMS (brief interview for mental status) was documented to be 13 (13 to 15 points suggests that cognition (all forms of knowing and awareness) intact. On 06/11/2024, the Office of Healthcare Assurance (OHCA) received an initial facility incident report (ACTs # 11011) of an incident of alleged abuse that occurred on 06/11/2024 at approximately 06:00 AM. The report included the following detail: The CNA (Certified Nurse Assistant)1 informed the RN (Registered Nurse)1 about the resident's (R1) injuries. Following the RN's assessment, the resident was found to have a scratch on the left temple, bruise on the left temple, a bruised and swollen left cheek, and scratches on the neck and chest. The resident has Dementia and was unable to provide details about how the injuries occurred and the CNA also reported being unaware of the circumstances surrounding the resident's injuries. The RN immediately removed the CNA from the residents due to the nature of the injury, which had no known cause.The CNA has been placed on leave pending investigation. A completed (final) report was received on 06/13/2024. The report included: .The resident initially reported the CNA fought with him using her closed fists to strike him because he did not want to get out of bed. He was sent to the emergency room for evaluation. He was noted with Mild tenderness with ecchymosis to left temporal forehead.The CNA reports while attempting to empty the resident's Foley, he exhibited physically aggressive behavior. He kicked her and threw an acrylic organizer filled with colored pencils at her. She reports that she blocked the attempts to strike her and believes that the resident injuries were sustained as a result of contact with the resident's urinal, which was in her hand while she tried to protect herself from the resident's attempts to strike her. Upon chart review, it was noted that the resident has a history of refusing care with episodes of verbal aggression. He had two episodes of previous physical aggression documented in the chart in April and May. There were no witnesses to the physical incident. Upon completion of the investigation, the allegation of abuse is unable to be substantiated. CNA1's contract has been canceled and she has been removed from care of resident's . The OHCA received a report from an external agency, Adult Protective Services (APS) on 06/17/2024, regarding the incident with R1, which was accepted for investigation. The report included: 1 On 6/11/24 at 7:08 AM, AV's (alleged victim/R1's) . had received injury to his forehead. Per NS, AV (alleged victim) reported AP (alleged perpetrator/CNA1) wanted AV to get up from bed but AV did not want to. AV was allegedly hit by AP after AV threw a water bottle at AP. 2. A police report (#24017123) was filed with the Maui Police Department (MPD) . A. AV's report to MPD: I. AV reported he was attacked by AP. II. Per AV, AP was trying to get him out of bed when he did not wish to and ended up being hit with a plastic urinal bottle on the head, causing a laceration to his friable (delicate) skin. III. AV indicated he just wanted to be left alone. Review of the Emergency Department provider note from encounter 06/11/2024 included the following entries: History was provided by Patient (R1): .presents to the Emergency Department for evaluation of status post physical assault . Patient reports he was assaulted by a CNA.He was told to get up at 6 am change his clothes, and to get up like everyone else. Patient refused. CNA pulled away the table from the side and started to pull and beat the patient up. Other nurse that gives patient medication was there to witness the assault, noting CNA told nurse that patient did not want to get up. No head strike. He has noted ecchymosis to forehead and scratches to his chest.Denies current pain at this time but notes nausea.Patient is awake, alert, and appropriate.mild tenderness with ecchymosis (bruising) to left temporal forehead.Based on the patient's history and presentation, my work up and conclusions are as follows assault, head injury, contusion. On 09/18/2024, at approximately 01:00 PM, interviewed R1's Physician (MD) in the conference room. He said he has cared for R1 since his admission in 2022. He said R1 has some dementia and was bipolar. MD said R1's level of consciousness had not changed much since his admission, and that R1 was with it. Discussed his progress note dated 06/11/2024 after he examined R1 when notified he had injuries of unknown cause. MD reviewed the progress note, and confirmed R1 was alert and oriented x4. He said he specifically asked him (R1) if he knew where he was, the date, and who the president was, and he was able to answer all correctly. MD said again, R1 knows what's going on. He went on to say R1 is bipolar and at times his attitude changes, but for the most part, he is pretty good. That day when I saw him, It really surprised me, with the bruise to the forward and left cheek. The laceration on the forearm was not bad. He seemed pretty with it. MD said the forehead looked traumatic, bright red and all bruised up. With him being bipolar, he can get grandiose and changes the story a bit, so there were some inconsistencies, but it was clear there was some kind of commotion. On 09/18/2024 conducted a telephone interview at 01:30 PM with the nurse supervisor (NS) that was on the night shift, He said he received a call from RN1 requesting assistance on 06/11/2024, when she identified new injuries to R1. The NS said he wrote a statement at the time, and that would be the most accurate, as did not want to miss any details since it had been a while since the incident. He said from his recall, the report and account of the incident that CNA1 gave, didn't line up with the report from the patient. Injuries weren't consistent with what she was describing. NS said his recall was that it was something to do with R1 not wanting to get up, and that it was too early for him. He went on to say Her story didn't match the way that care should be delivered. If it was self-defense when he picked a pencil holder and he started using as a weapon. At any point, you can step away. Outside an emotional situation, anyone doing the right thing should back away. On 09/18/2024 conducted a telephone interview at 02:40 PM with RN1, who CNA1 reported the injuries to on 06/11/2024. She said she was passing meds, went into R1's room a little before 06:00 AM, and he was fine at that time. RN1 gave him medications and went to the other end of the hall to continue med pass. A short time later, CNA1 came and got her. RN1 stated She (CNA1) said, I can't take it anymore, He's (R1) not listening, throwing things at me and not cooperating. RN1 went on to say it was not uncommon for R1 to refuse care. She said he would tell you he doesn't want something done, so we just say OK, and go back and try again, or send someone else in. She said CNA1 kept repeating he was trying to swing at me. RN1 said she immediately went to the room with CNA1. She said when she saw R1 he had a bruise on the top of his head and small cut. She said she asked CNA1 how he got it, and CNA1 kept trying to describe where she had been located in the room and that she was trying to empty the Foley bag. She went on to say CNA1 pointed to a plastic cubby (container) full of R1's personal items, and a water hydro [NAME], and said Don't you think that hurts when that's thrown at you? CNA1 said R1 had the bin over his head, and she had the urinal in her hand. At that point, RN1 said R1 started to talk and said, She hit me with that. RN1 said the bruising R1 had, could not have been caused by the plastic urinal because they are very thin plastic. She said CNA1 and R1 were going back and forth arguing. RN1 said CNA1 kept saying he kicked me in the back. She said R1 responded by saying Yea, and you punched me too. RN1 said she kept asking CNA1 what happened, and she just responded, she doesn't know. R1 said, What do you think, I hit myself? To that comment from R1, CNA1 responded No. RN1 said she and CNA1 left the room, and when the NS arrived, they assessed R1 more. She said he had a bruise on the top of head, by the forehead, the left temple area was swollen, firm to touch and a pretty hard hit. She said at that time they saw a scratch on chest and a skin tear to his arm, almost looked like a semi-circle. RN1 said she never got an answer from CNA1 how he got the injuries. She described R1 as pretty oriented, sometimes gets confused, and Overall, he just refuses care, until we find someone, he will allow to change him. RN1 said There was no confusion that day at all, he was sure of what happened. Sometimes his story changed a bit afterward, and I'd remind him I was there that day. RN1 did not witness the incident. On 09/19/2024 at 11:30 AM, observed R1 in bed, watching TV. He appeared well kept, had clean linens, and had no visible injuries or skin abnormalities. R1 said he felt safe in the facility, and said they were taking good care of him. He was cooperative, oriented, and able to carry on a pleasant conversation. On 09/19/2024 at 11:40 AM, inspected the urinals used at the facility. The urinals are thin plastic and made smooth to prevent scratches during use. On 09/19/2024 at 12:00 PM, reviewed pictures of R1's wounds that were provided by the facility. The pictures matched the description of injuries as described above. There was a large dark area of ecchymosis to the left upper forehead, as well as dark ecchymosis to the left check in front of the ear. In addition, there was noted redness above the left eyebrow and visible scratch type mark that ran across his upper chest. The age of the skin tears on his arm were not able to be determined by the pictures. The extent of the injuries noted in the pictures would not be consistent with a single accidental encounter with the urinal. 2) R2 is an [AGE] year-old female with a history of intellectual disability and legal blindness. She has been a resident at the facility since July 2022. R2's hearing is functional for conversation, but she does not always answer questions appropriately due to her intellectual disability. She is able to follow simple commands and is a one person assist for transfers and requires assist for meals. On 08/10/2024, OHCA received an initial report from the facility regarding a sexual abuse that was observed by a staff member. The report included a CNA entered the resident activity room and witnessed resident R3 with his hand on resident R2's breast.R3 was verbally instructed to remove his hand from R2 and both residents were physically separated by CNA immediately. Resident (R3) advised that he cannot participate in this type of behavior. Staff assigned to supervise R3 24/7 while a thorough investigation is completed. Police were called . The completed report was sent 08/15/2024 and included A thorough investigation was completed 8/10-8/15/24, including chart review, and interviews of CNA, R2 and R3. CNA2 reported entering the family room and witnessing R3's hand inside R2's clothing, cupping her breast. R2 was mumbling and pushing R3's hands away.When interviewed R2 was unable to recall any events.When interviewed R3 denies touching R2's breast but admits he was touching her abdomen, and his hand was inside her shirt. The investigation finds that abuse allegation is substantiated. Action taken after the incident included: R3 was provided 1:1 supervision 8/10-8/12/24. Welfare checks were done for R2 with no observed injury/harm. On 8/12/245, to protect vulnerable female residents in the facility, R3 was transferred to a private room on another unit where one wing houses male residents only. On 8/13/24, R3 became verbally aggressive and hit a staff. De-escalation techniques were unsuccessful and R3 began entering other residents' rooms. He was transferred to an acute care facility for treatment of behavioral changes and remains at the hospital waiting placement at a different facility. On 09/19/2024 at 11:40 AM, observed R2 in the family room with a staff member present. She was in a wheelchair and appeared well kept. R2 had a small, zippered purse with several small beads inside. She repetitively opened the purse, took beads out and the put them back in the purse. R2 is legally blind, does respond when spoken to, but was not interviewable. 3) Document review revealed the following: - The facility provided mandatory education on Preventing, Recognizing, and Reporting Abuse for all staff in April 2024. - It was confirmed the facility policy is to conduct background checks for all staff prior to hire. Contracted CNA1 had documentation on file of background check completed by the vendor on 06/03/2023. - The facility provided documentation CNA1 completed orientation that included Abuse Elder Justice Act Update, Preventing, Recognizing, and Reporting Abuse, Essentials of Resident's Rights, and Communication with Individuals with Alzheimer's & Dementia. The facility has developed and implemented policy and procedures related to abuse, titled Abuse: Patient/Resident, last reviewed 03/08/2024. The facility followed the policy and immediately removed the alleged perpetrators, protected the residents, notified appropriate authorities, and completed thorough investigations.