Based on observation, interview, and record review, the facility failed to ensure a resident's plan of care for behavioral health was implemented and evaluated after having physical behavioral symptoms directed towards staff and other residents, document a resident's behaviors in the clinical record, document interventions in response to such behaviors, document the reasoning for administration of an intramuscular (IM) injection of antianxiety and antipsychotic medications, and ensure other residents' safety was maintained during behavioral episodes to where a resident (Resident E) was found to have their hands around another resident (Resident F's) neck that resulted in redness. Resident F had felt fearful, anxious, and the need to relocate to another nursing facility. Findings include: 1a. The clinical record for Resident E was reviewed on 5/1/24 at 11:00 a.m. The diagnoses included, but were not limited to, Huntington's disease, extrapyramidal and movement disorder, psychosis, anxiety disorder, major depressive disorder, schizophrenia, and insomnia. A significant change minimum data set (MDS) assessment, dated 12/19/23, indicated severe cognitive impairment and physical behavior directed towards others that occurred in 1-3 days. A quarterly MDS assessment, dated 3/19/24, indicated severe cognitive impairment and physical behavior directed towards others that occurred in 1-3 days. An activities care plan, revised 4/25/24, indicated Resident E prefers to engage in independent leisure activities such as playing his X-box, watching TV/movies, listening to music, snacking, daily visits with family. At times, resident chooses to stay awake through the night playing video games and watching TV. The interventions included to encourage/invite Resident E to group activities and provide transportation to and from activities, provide a large activity calendar each month, and provide resident with activities supplies. A care plan, revised on 4/25/24, indicated Resident E has Huntington's disease and may experience: delusions, hallucinations, paranoia, lack of concentration, mental confusion, memory loss, involuntary movements, compulsive behaviors, irritability, lack of restraint, mood swings, and chorea (a symptom that causes involuntary, irregular or unpredictable muscle movements). The interventions included to administer medications as ordered and notify the medical director as needed as the only interventions. There had been no added interventions since 1/15/21. A care plan related to the diagnosis of schizophrenia and depressive disorder, revised 4/25/24, included the interventions to continue current mental health services, family involvement in care, therapy evaluations as needed, socialization/leisure/recreation activities, and supportive counseling from nursing facility staff. There had been no added interventions since 3/18/21. A care plan, revised 4/25/24 but initiated on 7/17/23, indicated Resident E had potential to appear physically aggressive at times with resident wanting to interact with others and due to tremors, it may cause unwanted contact with others. The interventions included administering medications as ordered, give resident choices about care and activities, modify environment, monitor for closeness in dining room with other residents, and psychiatric consult as needed. There had been no added interventions since 7/17/23. A care plan for physical aggression, dated 4/12/24, indicated a history of physical aggression towards others related to Huntington's disease and impulse control deficits. The interventions included, but not limited to, the following: - Administer medications as ordered, - Anticipate and meet the resident's needs, - Discuss the resident's behavior, if reasonable, - Intervene as necessary to protect the rights and safety of others, & - Monitor behavior episodes and attempt to determine underlying cause. A behavior note, dated 12/12/23 at 10:36 a.m., indicated the following, .IDT [interdisciplinary team] note. Resident in dining room for breakfast and left his table and went to another resident's table. Resident states that he was trying to get the attention of the other resident. Resident grabbed other resident's arm to get his attention causing a skin tear to other resident's left hand and bruising to left forearm. Staff with attempted to talk with, remove, redirect and offer care helped behaviors to decrease and eventually stop . A behavior communication form, dated 12/12/23, indicated Resident E grabbed another resident's arm to get their attention and caused a skin tear and bruising. There were interventions listed that were utilized and deemed effective. A behavior note, dated 12/13/23 at 6:12 a.m., indicated the following, .pt [patient] woke up at approx [approximately] 0500 [5:00 a.m.] agitated d/t [due to] unknown cause. pt started getting physically aggressive c [with] other pt in common area. when staff attempted to intervene [name of Resident E] began getting aggressive c [with] staff. staff eventually able to physically pick up patient and take to room. pt keeps attempting to come back out to common area to approach the same patient. poa [power of attorney] contacted, left vm [voicemail]. going to be in touch with hospice per day shift nurse when they open at 0700 [7:00 a.m.] A behavior communication form, dated 12/13/23 at 8:00 a.m., indicated Resident E was extremely agitated with repetitive verbalization and aggressively wheeling himself up and down the hallways. He was persistent with attempting to go up to other residents in an aggressive manner. Staff intervened before Resident E was able to approach any other resident. Resident E was combative with staff. Resident was grabbing arms, hands, and twisting while attempting to bite the staff. The PRN (as needed) intramuscular injection was administered and deemed effective. The two events where Resident E became physical with another resident was not reported to the Indiana Department of Health. There were no further names or description of the other residents that Resident E came into contact with on 12/12/23 and 12/13/23. There were no follow up notes in Resident E's clinical record to indicate if a root cause of the physical contact was discussed or determined. An administration note, dated 12/13/23 at 1:51 p.m., indicated a lorazepam (antianxiety) injection was administered to Resident E's left arm at 8:20 a.m. on 12/13/23 in regards to aggressive behavior. There was no indication of what was occurring with Resident E prior to administration of the antianxiety injection along with attempts that staff made in response to Resident E being aggressive. A physician order, dated 12/13/23, was noted for an intramuscular (IM) injection of Haldol and lorazepam every 6 hours as needed for aggression. A psychotherapy progress note, dated 12/13/23, indicated the following, .Three weeks ago, the patient's antipsychotic medication was increased by the Hospice provider due to behavioral disturbances, including recent physical aggression towards other residents .The patient's perception of reality was impaired, consistent with the psychotic disorder .Insight into mental health needs was poor, and judgement was compromised, as evidenced by the denial of reported behavioral disturbances .Recommendations .you may wish to consider the medical appropriateness of adding Haldol po [by mouth] bid [twice daily] for better control of psychosis resulting in aggression An administration note, dated 12/16/23 at 7:00 a.m., indicated PRN lorazepam injection was administered. There was no documentation on what behavior was occurring, staff response/interventions to any behaviors, and follow up to any behaviors that were occurring. An administration note, dated 12/16/23 at 10:00 a.m., indicated PRN Haldol injection was administered for aggression. There was no documentation on what behavior was occurring, staff response/interventions to any behaviors, and follow up to any behaviors that were occurring. An administration note, dated 12/16/23, indicated the PRN lorazepam and Haldol injections were listed as ineffective. A progress note, dated 12/16/23 at 1:24 p.m., indicated Resident E was sent to the emergency room at 10:45 a.m. due to extreme aggression. They returned to the facility the same day. A behavior communication form, dated 12/20/23, indicated Resident E had to be removed from 2 resident rooms due to him wandering into those rooms. A psychotherapy progress note, dated 12/26/23, indicated the following, .Recommendations .2. Facility staff should re-consult if current condition is exacerbated or new symptoms arise. Will follow up as appropriate An administration note, dated 1/8/24 at 4:00 p.m., indicated a lorazepam injection administration was effective. There were no indications on why the injection was administered or what interventions were attempted prior to the administration of the injection. An administration note, dated 3/17/24 at 9:45 a.m., indicated a lorazepam injection was administered due to aggressive behaviors towards staff and other residents. Resident E grabbed, squeezed, and twisted staff arms. Resident was grabbing belongings to other residents and attempting to hit. Resident E remained aggressive despite being taken to a less stimulating environment. The injection was listed as effective. An administration note, dated 4/4/24 at 12:32 a.m., indicated a lorazepam injection was administered but no indication why the injection was administered and what interventions were attempted prior to administration of the injection. The injection was listed as effective. An administration note, dated 4/11/24 at 5:40 p.m., indicated a lorazepam injection was administered but no indication why the injection was administered and what interventions were attempted prior to administration of the injection. The injection was listed as effective. A psychosocial note, dated 4/12/24 at 10:37 a.m., indicated the following, Resident could not verbalize recall of incident w/ [with] another resident on 4/11/24 An incident note, dated 4/12/24 at 3:54 p.m., indicated Resident E was put on 15-minute checks and redness was noted to Resident F's neck at the time of incident. Resident E's 15-minute checks were stopped on 4/12/24 at 3:15 p.m. Resident E had been pleasant watching video games at that time. An incident reported to the Indiana State Department of Health survey report system, dated 4/11/24 at 2:45 p.m., indicated staff responded to Resident F's room to where Resident E was observed to have his hands around Resident F's neck. The immediate action taken listed Resident E to continue to be followed by the facility psychiatric provider. There were no further psychiatric/psychotherapy notes for Resident E in the clinical record since 12/26/23. An interview conducted with Resident F, on 5/1/24 at 11:38 a.m., indicated she was choked. She indicated she was sitting in the doorway, in her wheelchair, with her back facing the entrance to her room. Resident E proceeded to approach her from behind and placed both of his hands around her neck. Resident F indicated it was very tight and made it difficult to breathe. She was anxious and fearful after the incident and ended up relocating to another nursing facility after the incident involving Resident E. The clinical record for Resident F was reviewed on 5/1/24 at 12:30 p.m. The diagnoses included, but were not limited to, cerebral infarction (damage to tissues in the brain due to loss of oxygen), hemiplegia (paralysis that affects only one side of the body), anemia, and hypertension. An admission MDS assessment, dated 1/17/24, indicated she was cognitively intact. An interview conducted with the Administrator in Training (AIT), on 5/1/24 at 1:25 p.m., indicated the incidents to where Resident E made physical contact with other residents on 12/12/23 and 12/13/23 did not appear to be reported to the Indiana Department of Health. AIT was not working at the facility during that time period. An interview conducted with Social Services Director (SSD), on 5/1/24 at 1:50 p.m., indicated the previous mental health provider went out of business. So, the mental health provider continued to see the residents, but it was Pro bono from January to March of 2024, and the provider did not leave any notes during that time period. We were going to switch to another provider, but we did not receive consents for Resident E to be seen by the new provider. We will be obtaining consent to Resident E can be seen by the current mental health provider. 1b. An observation conducted of Resident E, on 4/30/24 at 10:37 a.m., of him laying in bed with the television on. An interview conducted with Licensed Practical Nurse (LPN) 2, on 4/30/24 at 11:04 a.m., indicated she gets worried about Resident E. He had made contact with other residents in the past. His behaviors come in spurts but it's not an everyday thing. Resident E's behaviors are random, and you never know why he's doing it. It's very difficult to communicate with Resident E due to the difficulty in understanding him. An observation conducted of Resident E, on 4/30/24 at 3:00 p.m., of him up in his wheelchair propelling himself going into the dining room. At 3:05 p.m., he proceeded to propel himself out of the main dining room. There was a female resident sitting in the dining room looking outside. There were no nursing staff within a close distance to Resident E during the observations in the dining room. An observation conducted of Resident E, on 5/1/24 at 1:00 p.m., of him up in his wheelchair sitting in the doorway looking outside of his room. His television was on. There was activities going on in the activity room down the hallway. An observation conducted of Resident E, on 5/1/24 at 1:30 p.m., of him propelling himself in the wheelchair by the common area just outside of the nurses' station. There was activities going on in the activity room down the hallway. An observation conducted of Resident E, on 5/1/24 at 4:30 p.m., of him sitting up in his wheelchair in the common area just outside of the nurses' station. There were no activities going on at that time. Resident E's room was observed with a gaming system located beside his television. A policy titled Behavior Management Policy, dated 11/28/19, was provided by the AIT on 4/30/24 at 2:15 p.m. The policy indicated the following, .It is the policy of this facility that Residents with a need to address Behavioral Health will receive services, receive trauma related care and services from a clinician who has expertise and knowledge of this type of service and referrals will be made .PROCEDURE .3. For Residents who have been identified as having on-going behaviors/mood alterations, a Behavior Tracking should be utilized for all observed issues .4. Social Services Director will use Behavior Documentation to guide in IDT discussion regarding Residents with symptoms and the effectiveness of interventions .5. If behavior/mood interventions were not effective, the IDT will review and determine if new interventions should be initiated .6. Social Services Director will communicate recommended interventions to all staff via the Care Plan .10. At least quarterly interdisciplinary meetings will be held to discuss all Residents on the behavior management program as well as those Residents receiving psychoactive medication who may be due for reduction. During the meeting Behavior Tracking and care plans will be reviewed. Interventions will be discussed and changed if necessary A policy titled Reportable Incidents and Unusual Occurrence, Abuse Prevention, Reporting, and Investigation Policy, revised 8/28/23, was provided by the AIT on 4/30/24 at 2:15 p.m. The policy indicated the following, .3. Physical Abuse .a. Resident to resident. May be considered abuse and an investigation should occur This citation relates to Complaints IN00432416 and IN00432418. 3.1-37(a) 3.1-43(a)(1)