**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 44 residents. The sample included 15 residents with two residents reviewed for dementia care. Based on record review and interviews, the facility failed to ensure staff provided person-centered care and services as related to dementia for Resident (R) 192. As a result, staff's inappropriate response to dementia-related behaviors resulted in a broken wrist for R192. Findings included: - R192 admitted to the facility on [DATE] and discharged on 06/24/22. The Electronic Medical Record (EMR) for R192 documented the following diagnoses: dementia with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function), encephalopathy (damage or disease that affects the brain), major depressive disorder major mood disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement). The admission Minimum Data Set (MDS) dated [DATE] documented R192 had a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. R192 required extensive assistance of one staff for his activities of daily living (ADLs). The MDS recorded R192 had no behaviors during the look back period. The ADL Care Area Assessment dated 04/20/22 documented R192 needed help with ADLs and mobility. R192 had poor safety awareness, poor decision-making skills, poor strength/endurance, muscle weakness, impaired balance, and impaired mobility. Contributing factors include deconditioning, Parkinson's disease with Lewy body dementia and encephalopathy. Factors that placed him at risk included poor safety awareness, impaired balance, impaired mobility, and gait difficulty. The Mood CAA dated 04/20/22 documented R192 was significantly more depressed than his last stay in the health center. R192 reported feeling sad, having trouble concentrating, speaking slower, and having thoughts he would be better off dead all of these on most days. R192 reported feeling tired and feeling bad about himself about half the time. R192 was not as functional or helpful as he once was. R192 felt he had no purpose and thought of no longer being alive would lessen him being a burden to his spouse. R192 would never do anything to harm himself because he did not believe in that. R192's Care Plan initiated on 04/15/22 recorded R192 required extensive assistance of one person for personal hygiene. The care plan problem dated 04/15/22 listed R192 was at risk for impaired communication. An intervention dated 04/15/22 directed staff to allow adequate time for the resident's response, incorporate alternate of communication such as music, song, or visual demonstration and directed staff to incorporate visual prompting, cues, or gestures. It further directed staff to minimize environmental stimuli, and provide clear, simple instructions. R192's Care Plan recorded an intervention dated 05/02/22 which directed staff to converse with the resident while providing cares. R192's Care Plan lacked direction to staff, prior to incident on 05/15/22, with regards to dementia related behaviors or resident centered interventions on redirection. A Behavior Note dated 04/18/22 documented R192 had aggressive behaviors and was noncompliant with everything. He was delusional and combative with staff and required one to one supervision. A Physician Note dated 04/19/22 recorded R192 had debility (physical weakness, especially as a result of illness) and dementia and staff were directed to continue supportive care. The note lacked mention of behaviors, delusions, or aggression. A Behavior Note dated 04/19/22 at 01:23 AM recorded R192 was combative when staff attempted to redirect. At 11:30 PM, R192 tried to crawl out of bed, staff assisted him back to bed, and R192 was unhappy. He accepted several sips of thickened water. A Behavior Note dated 04/19/22 at 01:29 AM recorded R192 was almost out of bed. When staff tried to reposition him, he hit the aide's hand during the process. R192 was asking about his relative and not making sense when he spoke. He stated he was ok. The note recorded R192 was on frequent checks due to a risk for falls and had visual hallucinations (perception of having seen something that was not actually there). The record lacked evidence of physician notification. A Behavior Note dated 04/22/22 at 09:40 PM recorded R192 was verbally and physically abusive to staff and noted hitting and kicking behaviors while staff tried to provide cares. He insisted he could take care of himself. R192 cursed and refused to be moved by placing his feet hard on the floor so staff were unable to move the wheelchair. A Behavior Note dated 04/22/22 at 09:54 PM documented R192 exhibited psychotic (mental disorder characterized by a disconnection from reality) behaviors such as seeing people in his room and imagining things that were not true. The record lacked evidence of physician notification. A Physician Note dated 04/26/22 recorded R192 had debility dementia and directed to continue supportive care. The note lacked mention of behaviors, hallucinations, or psychotic episodes. An Incident Note dated 05/15/22 recorded R192 was complaining of pressure on his right wrist after an incident with the [unidentified] aid. At about 06:00 AM the aide tried to clean the resident's face when the resident grabbed her hand. He told the aide to go away but held on to her hand. The aide asked the resident to let go, but he did not. The aide then got ahold of the resident's right arm and, as she tried to free her hand, the aid heard a pop at the resident's wrist. The resident stated that he had no pain unless he tried to twist his hand. There was mild redness at the wrist. Staff notified the physician and received an order for an x-ray (diagnostic picture) of the right forearm. An Incident Note dated 05/15/22 recorded R192 denied pain, but reported pressure and stated it hurt to rotate his wrist out, and his pinkie finger was bothering him. Staff advised R192 not to move the hand. Staff asked R192 if he was afraid of his caregivers and he stated that he was not. The note further documented when staff asked R192 if he felt that it [no further explanation noted] was under malicious intent, R192 stated that it was lack of education and experience. The X-ray was completed and R192 went to breakfast. Upon receipt of the report, the physician was notified as well as Administrative Nurse D. Staff received a new order to send R192 to the emergency room (ER). The General Diagnostic radiology (x-ray) report dated 05/15/22 for R192 documented an acute spiral type of fracture with 1-millimeter displacement and minimal angulation. nondisplaced fracture of the right distal ulna (wrist bone). The Facility Investigation dated 05/19/22 documented R192 admitted to the facility for short term rehabilitation. He had diagnoses of Parkinson's disease and Lewy body dementia. The investigation recorded R192 had a history of being combative with team members during cares. The investigation recorded at approximately 06:00 AM on 05/15/22 Certified Nurse Aid (CNA) M went into R192's room to assist him to the restroom; R192 said he did not need to use the bathroom and did not need any help. CNA M noted saliva dripping from R192's mouth so she grabbed a tissue to assist him. R192 grabbed CNA M's arm and commanded her to get out. CNA M told R192 she would be glad to leave if R192 would let go of her arm. The investigation recorded CNA M asked R192 to let go three times, and each time R192 grabbed her harder and yelled louder for to leave. CNA M reached for R192's hand to try to pry it off hers and she heard a popping noise. The CNA then went to notify Licensed Nurse (LN) I. The investigation further documented LN I asked R192 what happened and R192 told LN I she broke it. The Witness Statement from CNA M recorded she went to the resident's room to offer him the toilet because earlier that morning he had refused. R192 said no he did not need to go, and he did not need CNA M's help. CNA M recorded she noted saliva falling from R192's mouth. She grabbed a tissue to clean it and R192 grabbed her hand and told her to get out. CNA M documented she told R192 she just wanted to clean his face and help him to the bathroom because he did not go earlier, but also told him he did not have to. CNA M recorded she told R192 to let go of her hand and she would leave and R192 tightened his grip. CNA M then told R192 he was hurting her arm and to let her go. R192 continued to squeeze harder so CNA M grabbed R192's hand and fingers to pry R192's hand away while CNA M pulled her arm back. During this action, CNA recorded she heard R192's s wrist pop. In an interview with CNA M on 08/04/22 at 01:50 PM, she stated on 05/15/22 she went in to R192's room to ask if R192 needed to go to the bathroom. R192 was in his wheelchair with his back towards her. As CNA M approached R192, she noticed he had saliva drooling from his mouth. CNA M then went into the bathroom to grab a washcloth to wipe the saliva from R192's mouth. CNA M said while attempting to wipe R192's mouth, she must have startled R192, and R192 grabbed her arm and told her to get out of his room. CNA M stated she repeatedly asked R192 to let go of her arm. R192 continued to grip her arm tighter, so she took her other hand and tried to pry R192's fingers loose from her arm. As she tried to pry R192's fingers off of her arm, both R192 and CNA M heard a pop. CNA M stated R192 had never acted this way before this incident. CNA M stated after the incident she immediately went and told the nurse about the incident. CNA M said she was suspended immediately and upon return to work, was educated on dementia training and how to handle a combative resident. CNA M stated she had dementia training/education when she was hired in 2020 and the facility did dementia training annually. CNA M stated the incident on 05/15/22 all happened so fast. CNA M said she felt she should have tried to calm him down before she attempted to pry him hand off her arm. On 08/04/22 at 02:18 PM CNA N stated she had completed dementia training/education. She said the Administrative Nurse D provided educational sheets on dementia care recently. CNA N stated she had never taken care of R192. On 08/04/22 at 03:50 PM Licensed Nurse (LN) G stated R192 had some behaviors while he was at the facility and usually, they were mild in nature. She completed dementia training annually as required and Administrative Nurse D occasionally passed out dementia education pamphlets to staff to review. On 08/04/22 at 04:23 PM Administrative Nurse D stated she became aware of the incident that happened with R192 and CNA M on 05/15/22, but was not in the facility at the time it happened. Administrative Nurse D stated CNA M was educated on dementia training, and how to care for a combative resident. The facility also held a mandatory staff meeting after the incident for the dementia education. R192 had been known to have some behaviors while he was a resident. The facility did not provide a policy for dementia care. The facility failed to ensure person centered care and services related to dementia and dementia related behaviors for R192, who had a history of aggressiveness and combativeness. As a result, staff 's inappropriate response to R192's dementia-related behaviors resulted in a wrist fracture for R192. On 05/16/22 the facility implemented the following corrective actions: Staff education on the following topics: How to respond too Combative Behavior in Dementia How to respond to Anger and Aggression in Dementia Understanding challenging Behaviors in Dementia The Difference Between Alzheimer's and Dementia Stages and Progression Lewy Body Dementia R192's plan of care was updated with resident-specific interventions that addressed his behaviors. The deficient practice, corrected prior to the survey, was cited as past noncompliance.