**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, and facility policy review, the facility failed to implement safety measures and interventions to protect residents on the Chronic Confusion and Dementing Illness (CCDI) Unit from resident to resident physical abuse from Resident #3, for 2 of 19 residents reviewed (Residents #2 and #7) that resided on the CCDI unit. Resident #3 had a history of physical violence directed at staff and resident's that included: On 7/8/23 alleged to have hit Resident #3 in the chest that caused an 8 X 10 centimeter (cm) purple bruise. On 7/10/23 Resident #3 was sent to the local emergency room (ER) for behavioral health placement before return to the facility. Resident #3 was described by facility on transfer documents as angry, agitated, with a history of physical aggression to residents and staff, raises fists to everyone. The resident returned to facility at 7:00 p.m. that same day and the facility implemented 15-minute checks. On 7/11/23 at 8:30 a.m. Resident #3 entered Resident #2's room and physically assaulted him as he laid in bed, striking him repeatedly in the head with his closed fist. The facility identified a census of 19 residents on the CCDI unit, total facility census 51. Findings Include: 1. The Minimum Data Set (MDS) for Resident #3 dated 6/14/2023 documented a Brief Interview of Mental Status (BIMS) score of 4 out of 15 indicating severe cognitive impairment. The MDS documented hallucinations and verbal behavioral symptoms directed towards others in the past 1-3 days. The MDS also documented the resident significantly intruded on the privacy of others, rejection of care that occurred in the past 1-3 days, wandered daily which put the resident at significant risk of getting to a potentially dangerous place and intruded on the privacy or activities of others. The MDS documented the resident independent for bed mobility, transfer, toilet use and walking. The MDS identified diagnosis that included Alzheimer's disease. Review of the Care Plan included a Focus Area: Resident has potential for mood/behavior issues related to diagnosis of Lewy body Dementia with behavior disturbance. Interventions included the following: Administer medications as directed, provide consistent routine, encourage family visits, socialization and activity attendance, monitor for potential unmet needs and resolve, monitor for significant changes in mental status and mood/behaviors and notify physician, provide reassurance and 1:1 as needed, Urinalysis as per orders dated 7/5/23, Send to ER for evaluation and treatment dated 7/10/23 and 7/11/23. The Care plan additionally identified a focus area: The resident uses psychotropic medications to aid in the management of mood/behavior issues with the diagnosis of Lewy body dementia with behavioral disturbance and delusions initiated on 6/21/23. Interventions included the following: a. On 7/5/23 Ativan 0.5 mg twice a day (BID) X 3 days. (Anti-anxiety medication). b. On 7/7/23 Extend Ativan x 14 days. 7/8/23 Zyprexa 2.5 mg daily (decrease hallucinations). c. On 7/10/23 Increase Ativan to 1 mg po BID, as needed (prn) and Zyprexa to 5 mg every evening. Record review of a Progress Notes for Resident #3 included the following: a. On 6/8/23, admitted to the CCDI unit, agitated by staff, verbally threatening staff. b. On 6/27/23, Agitated at supper, tapped finger firmly on staff's chest. c. On 6/29/23, Attempted to push staff with the intent to knock over. Visual and auditory hallucinations. d. On 7/2/23, Yelled at peer, drawing fist back and threatened to hit if continued to call him names. e. On 7/4/23, Attempted to choke staff person, had hands wrapped around neck. f. On 7/8/23 at 7:00 a.m., aggressive behavior toward peer this morning before breakfast. Resident observed in Resident # 7's room, fist raised and hit bed with fist. g. On 7/8/23 at 1:45 p.m., threatening to kill staff unprovoked. Redirection, snacks, 1:1 without success. As needed antianxiety medication administered. h. On 7/8/23 at 2:30 p.m., Resident walked up to staff person and swung fist hitting in the face. i. On 7/10/23 10:30 a.m., Director of Nursing (DON) investigated peer complaint of striking her (Resident #7), and notes regarding increased aggression. Spoke with family and need to send to ER of choice. At 12:30 p.m., transport team and Sheriff at the facility, Resident #3 goes willingly. j. On 7/10/23 7:00 p.m., returned from Emergency Room. New orders to increase antianxiety medication and medication for hallucinations. Review of a facility form titled, Resident Transfer Information Form for Resident #3 dated 7/10/23, signed by the DON, documented the reason for transfer to the ER as: Resident physically assaulted another resident leaving a large bruise. Resident very angry, agitated, choked staff member, and raises fist to everyone. Requires behavioral health placement before return to the facility. Review of an un-named facility form documented every 15-minute checks were initiated on 7/10/23 at 7:00 p.m. The form is signed as completed at 15-minute intervals until 7/11/23 at 9:15 a.m., when documented that resident had left the building. Review of a Progress Note dated 7/11/23 included the following entries documented by Staff C, Registered Nurse (RN): a. At 8:00 a.m., in dining room for breakfast. b. At 8:15 a.m., standing in the hallway next to a laundry bin, located outside room [ROOM NUMBER]. c. At 8:30 a.m., as returning to the nurses desk, hear male resident calling out. DON on unit and rushed into room [ROOM NUMBER] where witnessed Resident #3 striking resident #2 repeatedly (5 or 6 times) in the face with a closed fist. d. At 8:32 a.m., 911 paged for need to transport resident. Resident at nurse's station until ambulance crew arrived. 1:1 staff at resident's side. e. At 9:10 a.m. Ambulance and two Sheriff's staff arrive, resident transported to local ER for evaluation. Review of a late entry on 7/11/23 at 7:35 a.m. documented that the provider was on the unit to see resident for second 30 day visit and follow up of ER visit yesterday. Resident pleasant. Interacts appropriately. In an interview on 9/26/23 at 2:10 p.m., Staff F, Certified Nursing Assistant (CNA) stated on 7/4/23 Resident #3 was in a female resident's room, Staff F responded and asked him to leave nicely, opened the door wider, and offered to take him to his room, and then all of the sudden he grabbed my neck and we both fell to the floor. Staff F described as very sudden, wasn't expecting, couldn't predict or anticipate. Stated that is was known that he could be physically and verbally aggressive, and if he was escalating or aggressive to call his wife and she would assist to calm him down, but this was so sudden. In an interview on 9/27/23 at 3:50 p.m., the DON and the Assistant Director of Nursing (ADON) reviewed the review of Progress Notes related to Resident #3's behaviors. They reported that they feel most of the residents on the CCDI unit have the risk of being physical and that they take adequate precaution. When asked about the decision to place Resident #3 on 15-minute checks when returned from the hospital instead of placing 1:1 supervision, the DON responded that they placed 15-minute checks because that was the resources they had available, and the ADON stated that in hindsight wished they had placed 1:1 supervision. 2. The MDS for Resident #7 dated 7/5/2023 documented a BIMS's score of 3 out of 15 indicating severe cognitive impairment. The MDS documented the resident had delusions and verbal behavioral symptoms directed towards others in the past 1-3 days. The MDS also documented rejection of care that occurred in the past 1-3 days. The MDS documented the resident independent for bed mobility, transfer, toilet use and walking. The MDS identified diagnosis that included unspecified dementia. Review of a Progress Note dated 7/8/23 at 7:00 a.m., initiated by Staff G, Licensed Practical Nurse (LPN) documented Resident #7 yelling. Staff responded to room and peer, Resident #3 was also in room. Resident #7 was noted to yell out, get this man out of my room, he hit me. Staff present reported that they had witnessed Resident #3 hit her bed, but not her person. 10:00 a.m. small blanchable pink area noted to Resident #7's left chest. 11:00 8 X 10.2 cm dark purple bruise to left chest. Review of a Progress Note dated 7/9/23 at 9:00 p.m., resident tearful when talking to staff about bruise to left chest. Resident #7 yells out at Resident #3 numerous times throughout the shift. During an interview on 9/28/23 at 10:10 a.m., Staff G, LPN stated that she was the nurse on the CCDI unit on 7/8/23. At approximately 7:00 a.m., Staff H, CNA came and got her because Resident #3 was in Resident #7's room. Staff H reported that she had witnessed Resident #3 in the room and hitting the bed, but not striking Resident #7. Staff G, LPN responded to the room and assessed Resident #7 who had a pink area on her left chest where she alleged had been hit by Resident #3. Staff G reported she had monitored the area and the same pink spot had developed into an 8 x 10 cm dark purple bruise by 11:00 a.m. Staff G recalled that throughout the shift Resident #7 had pointed at Resident #3 and made comments about him, indicating that she had not wanted him near her. Staff G stated that she was not aware of any special interventions for Resident #3 when agitated or aggressive and had been unaware that he had choked a staff person until after the incident had occurred on 7/8/23. During an interview on 9/26/23 at 1:07 p.m., Staff H stated Resident #3's behaviors had escalated and the interventions that had been working for him were no longer working, and he wouldn't allow care because staff were not his wife. Observation and interview on 9/27/23 at 4:30 p.m. Resident #7 was observed seated in the dining room for an activity. Resident #7 was pleasant and cheerful, smiling, and responded that she felt safe and comfortable. 3. The Minimum Data Set (MDS) for Resident #2 dated 6/7/2023 documented a BIMS's score of 3 out of 15 indicating severe cognitive impairment. The MDS documented verbal behavioral symptoms directed towards others in the past 1-3 days. The MDS also documented rejection of care that occurred in the past 1-3 days. The MDS documented the resident independent for bed mobility, transfer, toilet use and walking. The MDS identified diagnosis that included non-Alzheimer's dementia. Review of an ER note dated 7/11/23 at 9:21 a.m. revealed Resident #2 presented to the ER as an assault victim. Reported Resident was in his bed at approximately 8:30 a.m. when another resident at the nursing facility came into his room and allegedly in an unprovoked fashion hit multiple times with his fists, to both the head and face. Staff deny that he had a loss of consciousness. He admits to pain around his left cheek. Assessment revealed some early ecchymosis to the left maxilla (jawbone) and left periorbital (around the eye) region. The summary noted no obvious skull or facial fracture. Observation and interview on 9/27/23 at 4:15 p.m. revealed Resident #2 seated in the area near the nurse's station, having a snack. Resident smiled, and responded that he thought he felt safe. In an interview on 9/28/23 at 10:34 a.m. Staff C, Registered Nurse (RN) confirmed she had worked on the unit on 7/11/23 and responded to the Resident to Resident altercation between Resident #3 and Resident #2. Stated she had just seen resident #3 minutes before in the hallway near a laundry hamper, and had gone to give another resident medication. Confirmed Resident #2 was in his bed, helped to remove Resident #3 from the room and then went back to assess Resident #2. Staff C recalled that Resident #2 was shook up, like in shock and disbelief, kept asking why would he do that, and why was he still here. Resident #2 stated that he got punched in his cheek and jaw. Stated that Resident #2 no longer talks about it, but recalled that he had talked about it the next day, had stated that another resident had hit him in the face. Record review of an undated Resident Protocol, entitled What to do in a Resident to Resident Altercation included the following: 1. Immediately separate the residents. 2. Notify charge nurse, charge nurse to immediately assess resident for injuries. 3. Charge nurse to immediately notify DON or designee and a report must be made to the state by the DON or designee within 2 hours. 4. Incident reports will be filled out on both residents (aggressor/victim) including skin sheets if needed, neuro checks if needed. 5. Physician will be notified. 6. Family will be notified. 7. Have witnesses write out witness statements. 8. Everything charted in the nurse's notes. 9. Must have an immediate intervention. 10. Continue shift assessment x 24 hours. The Facility Policy Titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy dated 10/22 defined, Resident to resident physical contact that occurs, which includes but is not limited to where residents are hit, slapped, pinched or kicked and results in physical harm, pain or mental anguish is considered resident to resident abuse. The facility will presume that instances of abuse cause physical harm, or pain or mental anguish in residents with cognitive and/or physical impairments which may result in a resident unable to communicate physical harm, pain or mental anguish, in the absence of evidence to the contrary. The policy further stated that all residents have the right to be free from abuse.