**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with staff the facility failed to protect a resident's right to be free from abuse (Resident #33) when a resident (Resident #324) physically pulled him to the floor causing a fall. During a second physical altercation Resident #324 grabbed hold of Resident #33 causing him to fall on his left hip. After the second fall Resident #33 was unable to move his left leg, complained of pain to the leg and hip, and was transferred to the hospital. The hospital x-ray identified an acute left femoral neck fracture (a break of the upper leg bone just below the joint that connects to the hip) with mild varus angulation (a displacement of the bone causing it to tilt inward towards the midline of the body). The hospital records revealed without surgical repair Resident #33 would be non-weightbearing and bed bound, and the decision was made to perform a surgical repair hemiarthroplasty (a prosthetic replacement of upper leg bone that connects to the hip). A reasonable person would have experienced fear, emotional distress, and pain by being physically abused in their home. The deficient practice resulted for 1 of 3 residents reviewed for abuse. Findings included: Resident #324 was admitted to the facility on [DATE] with diagnosis including neurocognitive disorder with Lewy bodies (a brain disorder that affects thinking movement, behavior, mood, and other body functions), Alzheimer's disease, and dementia. The care plan initiated on 10/12/23 included focus problems areas for Resident #324's behavioral symptoms that required admission to the memory support unit related to dementia with behaviors, Lewy body dementia, Alzheimer's, a history of wandering and exit seeking behaviors. The goals included care was provided with dignity minimizing risk for injury and encourage easy transition to the unit as evidenced by acceptance of care, lack of injury, and participation in activities on the unit through the next review. Interventions included orient to memory care unit, room, anticipate and meet all activities of daily living care needs, and provide assistance as appropriate. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #324's cognition was severely impaired, and he demonstrated physical and verbal behaviors directed towards others for 1 to 3 days during the review period. He was independent with transfers and walking, did not use a device for mobility, and did not fall since admission. Resident #33 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, osteoporosis, and macular degeneration. The care plan initiated on 11/07/23 included problem focus areas for Resident #33's diagnoses of cognitive loss and dementia that required admission to the memory support unit and being at risk for falls related to dementia with behaviors, agitation, medications, and impaired mobility. The goals included not to sustain injury and/or serious injury, provide care with dignity and minimize risk for injury, encourage easy transition to unit as evidence by acceptance of care and lack of injury through the next review. Interventions included cue for safety awareness, redirect when entering an unsafe area, and approach in a calm, friendly and non-threatening manner. The admission MDS assessment dated [DATE] revealed Resident #33's cognition was severely impaired and physical and verbal behaviors directed towards others and wandering had occurred 1 to 3 days during the review period. He required supervision with transfers and walking, had no range of motion impairment, and used a walker for mobility. The MDS indicated Resident #33 had no falls since admission and there had been no recent surgery and no major joint replacement or orthopedic surgery. Review of the nurse progress note written on 11/16/23 at 10:54 PM revealed Resident #33 had got out of bed and was lost and screaming hello in the hallway. He was given a snack and juice and sat with the nurse and Nurse Aide (NA). He was calm for approximately 15 minutes then begun to scream and tried to get close to the face of the NA and his anger and aggressive behavior was unpredictable. Review of the progress note written by Nurse #5 on 11/18/23 at 4:28 AM revealed Resident #324 was wandering around the unit earlier with no aggressive behaviors and went to bed around 11:30 PM for a few hours then got back up for a while then went back to bed. A progress note for the date and time of 11/18/23 at 5:50 AM was documented as a late entry on 11/19/23 at 6:51 AM by Nurse #5. The note read in part, Nurse #5 was called down the hall for assistance and noted Resident #33 laying on the floor on his left side with his walker in front of him and two NA staff at his side. Resident #33 was able to move all extremities except the left lower and was guarding it. When asked by Nurse #5 Resident #33 stated he could not straighten his left leg and complained of pain to the leg and hip and repeated, He picked me up like a rag doll and threw me. Nurse #6 called the on-call Nurse Practitioner and the ambulance to send Resident #33 to the emergency room for evaluation and treatment as indicated. Review of the fall event report dated 11/18/23 at 5:55 AM documented by Nurse #5 indicated an unwitnessed fall occurred in the hallway and Resident #33 exhibited pain in the left hip with limited range of motion in the lower extremity and a rotation deformity/shortening of the left lower extremity and a skin tear to the right ear. During a phone interview on 08/29/24 at 1:35 PM Nurse #5 revealed she was in the office at the nurse station near the 100 living room charting when the NA called for her. She observed Resident #33 on the floor (on the far end of unit). She did not recall any reports related to behaviors from staff involving Resident #33 or #324 during her shift and did not recall the last time she saw them. If she was made aware of any behaviors between them she would have watched and kept track of where the residents were and kept them apart from each other. She described residents on the dementia unit wander, and some got up early and she thought that was what happened when the altercations occurred. She did not watch the video camera footage and revealed she had worked on 11/18/23 to fill in the shift. She described her assessment of Resident #33 revealed he was not able to move his leg and had pain and the fall occurred close to shift change and the day shift Nurse #6 helped with sending him to the hospital. She did observe Resident #324 after the incident happened and stated he was walking around with no change in his condition. Review of the progress note written by Nurse #6 on 11/18/23 at 6:10 AM read in part, Night shift reported Resident #33 fell and stated he was pushed. Resident #33 made the comment, He just picked me up and threw me down like a ragdoll. There was another resident sitting in the living area below the hallway where Resident #33 was, and they were separated. A progress note written by Nurse #6 on 11/18/24 at 6:24 AM read in part, Resident #33 continued to state he was pushed down by another resident and made the comment several times, He just picked me up and threw me around like I wasn't nothing. During an interview on 08/28/24 at 11:04 AM Nurse #6 revealed she reviewed the video camera footage and described she saw Resident #33 and Resident #324 on the far end of the unit around 200 living room with no staff around. Resident #324 was sitting in a chair when Resident #33 used his walker to bump the chair, and it appeared he did it on purpose more than 1 time. She then saw Resident #324 stand up and physically throw Resident #33 to the floor. Resident #33 got himself off the floor, got his walker, and stayed in the 200 living room area but Resident #324 left. Then Resident #33 went around the corner onto the hallway in front of the soiled utility room and rammed his walker into the door several times. Resident #324 came back to where Resident #33 was and put his hands on Resident #33 and the walker was behind and off to the side of Resident #33. She stated when Resident #324 put his hands on Resident #33 he went backwards, and it appeared he tripped over the wheel of walker. Nurse #6 revealed at the time of the fall she did ask Resident #324 what happened, but he was not able to articulate and did not recall anything. She revealed Resident #324 was ambulatory and described he was not always easy to redirect and could become aggressive towards staff but to her knowledge not with other residents. He tried to help staff with other residents and when redirected would raise his voice or attempt to hit, he struggled with sleep, and had sundowning behaviors (increased confusion, agitation, and restlessness). She described Resident #33 dementia was not as advanced and he did say to staff. He threw me around like a ragdoll and picked me up like nothing several times. She described Resident #33 behaviors he would yell out a lot, be aggressive towards staff during care and verbally aggressive towards other residents by saying shut up or move but she did not recall him being physically aggressive towards other residents. Review of the initial 24 hour report revealed the facility became aware of the incident on 11/18/2023 at 6:45 AM. The facility self-reported to the state agency on 11/18/23 at 8:32 AM an allegation of abuse based on the statement made by Resident #33, He pushed me as he pointed at Resident #324. Review of the 5-day investigation report revealed the former Administrator completed the investigation and noted there were no witnesses but after review of the facility's video camera footage two back to back physical altercations were observed between Resident #33 and Resident #324. The summary of the investigation read in part, Resident #33 bumped his walker into the chair of Resident #324 twice and it appeared intentional. Resident #324 then pulled Resident #33 to his back and walked away. Resident #33 did not appear injured and got up and walked away. Resident #33 begun to bang his walker into a door and was approached by Resident #324. Resident #324 tripped over the wheel of the walker and tried to catch himself causing Resident #33 to fall on his left hip. The report indicated the incident resulted in physical harm from the second fall when Resident #33 was reported to have a left hip fracture and resulted in serious bodily injury and the allegation of abuse was substantiated. Review of the statement written by NA #3 read in part, On the morning of 11/18/23 I was charting when me and my partner heard a resident screaming for help, we got up walked towards Resident #33 and found him on the floor. When asked what happened Resident #33 stated another resident hit him and threw him on the ground and he had pain to his left hip. Me and NA #4 asked Resident #324 if he hit Resident #33 and he stated yes but he hit me as well. Prior to the altercation Resident #33 had been redirected away from Resident #324 because he would agitate him with words and while asleep in the common living room and would try to wake him or run over his feet with his walker or scream while other residents were sleeping. During a phone interview on 08/28/24 at 2:12 PM NA #3 described Resident #33's behaviors included he used his walker to run over residents' feet and would say mean stuff like, It doesn't matter I can do whatever I want. She revealed Resident #324 was calm and she had not witnessed any type of behavior from him and during her shift on 11/18/23 and he had been up walking around and mostly stayed in the 100 living room area. She revealed on 11/18/23 she witnessed Resident #33 use his walker to run over Resident #324's feet while he was sitting in a chair. She redirected Resident #33 and told him to quit and sat with him and explained Resident #324 was going to get mad. From what she recalled Resident #33 was assisted to bed and she had done a round with NA #4, and she was charting in the 100 living room area (out of sight of 200 living room). It was approximately 45 minutes later she heard Resident #33 yell for help and found him on the floor at the 200 rooms on the far end of the unit. Resident #33 and #324 were the only two residents out of bed at that time and when she asked what happened Resident #33 pointed at Resident #324 and stated, He slammed me on the floor. Resident #324 was asked what happened, and he looked at Resident #33 and stated, I slammed him on the floor. NA #3 revealed she did not watch the video camera footage but Resident #33 and #324 were the only two up at the time of the fall. She stated residents were redirected to prevent altercations, but normally she did not work on the memory care/dementia unit and described most need 2-person assist making it hard to track where residents were when 2 NA staff worked. Review of the statement written by NA #4 read in part, Around 5:45 AM she was charting in the 100 living room area when she heard resident #33 yell out. I saw Resident #33 lying on the floor in the hallway on opposite end of the unit near the living room area (200 living room). Resident #33 stated, The guy picked him up like he was nothing and hit him and broke his glasses. Resident #324 had the glasses in his possession and appeared to be agitated and uncooperative when I tried to get them from him. Resident #33 complained of severe leg pain and when touched yelled and winced in pain. During a phone interview on 08/29/24 at 4:30 PM NA #4 revealed her, and NA #3 were charting at the table in the 100 living room area located at front end of the memory support unit and Nurse #5 was in the nurse station located by 100 living room when the altercations occurred. She stated she never saw Resident #324 put his hands on Resident #33 and thought Resident #33 was in his room. She and NA #3 had just done rounds and found Resident #33 getting out of bed, so they got him up and dressed and left him sitting in his room by the 200 living room area. She described Resident #33 was ambulatory and used a walker and Resident #324 walked independently and got around easily. She did not witness the falls and revealed the area where nursing staff were they could not see residents on the far side of unit when in the 200 living room. She did hear Resident #33 yell out and stated the second fall happened by the soiled utility room where the 200 rooms were located. She described Resident #33 was on the ground with his walker on top of him and Resident #324 had the glasses in his back pocket. She asked Resident #33 what happened, and he said he threw me down and pointed at Resident #324. She asked Resident #324 if he threw Resident #33 down and he said no and walked away. She revealed earlier that night Resident #324 was pacing but she did not witness him be aggressive or irritable and Resident #33 had slept good. She did not observe Resident #33 use his walker to bump into Resident #324. She revealed Resident #324 did have history of aggressive behaviors towards staff but not residents and she did not know of any aggressive behaviors from Resident #33. Prior to fall Resident #324 sat in the 200 hall living room and been up most of the night but did not recall Resident #33 being out of his room after they got him out of bed. She revealed her and NA #3 had just done a round around 5:00 or 5:15 AM and checked every resident. During a phone interview on 08/29/24 at 11:05 AM the former Administer stated he was notified early in the morning on 11/18/23 Resident #33 had fallen, and he came to the facility to investigate. After watching the video, he reported the incident to the state agency due to it appeared the second fall happened because Resident #33 was pushed. He stated the falls were unwitnessed and named the former Director of Nursing (DON) and Nurse #6 had also watched the video footage. He stated initially they thought the second fall happened because Resident #324 pushed Resident #33 but after the video was slowed down, he saw Resident #324's foot get caught in wheel of Resident #33's walker. He revealed it was clear the residents were having some kind on disagreement and described the first physical altercation occurred when Resident #33 nudged either the table or chair of Resident #324 and he got up and pushed Resident #33 causing him to fall to the floor and his glasses to come off. He saw Resident #324 pick the glasses up off the floor after the first altercation. After that Resident #33 started banging his walker into the wall and that got Resident #324's attention and he walked down the hallway towards Resident #33. Resident #33 started to use his walker to make a swooping motion and Resident #324's foot got tangled in the wheel of the walker. Resident #324 started to fall and when he tried to catch himself, he reached and grabbed Resident #33's shoulder and that's when Resident #33 fell and landed on his hip. Resident #33 did not get up and was sent to the hospital on [DATE]. Resident #324 was sent to the hospital on [DATE] for a psych evaluation and cleared he was not a danger to himself, or others and they could not keep him. When Resident #324 returned to facility he was placed on 1:1 observation until the provider saw him. He revealed after the incident it was his last week as the Administrator at the facility and he did not recall all the corrective actions put in place, but did speak about the plan with his replacement and passed everything off him. During an interview on 08/30/24 at 2:34 PM the former DON recalled what he observed on the video footage was Resident #324 sitting in a chair in the 200 living room area located in the back of the unit where the first physical altercation occurred. He revealed Resident #33 used his walker to nudge Resident #324 and Resident #324 got up and wrapped his arms around Resident #33 and pulled him to the floor. Resident #324 then walked away and out of view of the camera and the opposite way where Resident #33 was. Resident #33 got up and walked approximately 25 to 35 feet to the 200 hallway and slammed his walker into wall. Resident #324 came back in view of the camera and went to Resident #33. He put his hands on Resident #33 and the two residents started to wrestle each other by putting their hands on each other's arms and hitting one another. They disengaged but stood together and then started again and it appeared Resident #324 lost his balance and he could not recall who tripped over the walker, and stated Resident #33 fell and he did not observe staff during the two altercations. During an interview on 08/28/24 at 1:54 PM the Interim Administrator revealed she was not in her position when the altercations occurred. She revealed the facility no longer had the video camera footage available to view. To her knowledge no request was made to save it and if not, the footage was only kept for 90 days. During an interview on 08/30/24 at 11:03 AM the Director of Nursing revealed she was not in her position when Resident #33 fell on [DATE]. She read the facility's incident report that described what happened during both physical altercations between Resident #33 and Resident #324. The DON stated if a staff member had been monitoring the 200 living area on the end of unit where the first altercation started and fall occurred, they would have been aware of Resident #33's behaviors and him agitating Resident #324 and be on alert to monitor the residents. The DON stated she considered the second fall and/or physical altercation was avoidable. During an interview on 08/30/24 at 1:42 PM the Interim Administrator stated it was her preference that staff be throughout the unit to monitor residents and there was a possibility the second fall and/or physical altercation could have been avoided. The facility provided the following corrective action plan with the correction date of 11/30/23: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 11/28 resident #33 was sent to the hospital for evaluation. Resident #324 was placed on 1:1 supervision and sent out to the hospital for psychiatric evaluation. Set #324 was placed back on 1:1 Supervision upon return to the facility on [DATE] until cleared by multiple providers. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. A 100% audit on mobile residents who resided on the unit was conducted on 11/22/23 by the administrator to determine who could be at risk for an altercation that result in a fall. The determination was that the risk was moderate. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. By 11:59 PM on 11/27/23 a 100% of staff will be educated on the abuse policies and procedures and deescalating techniques by the administrator designated person. Those who have not been educated will be removed from the schedule until reviewing the education. On 11/27/23 the systemic change that occurred was putting a gradual dose reduction (GDR) binder in place at each nurse's station which would include the current GDRs and resident care profiles with behavioral care plan approaches. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. By 11/29/23 the Interdisciplinary Team (IDT) will have compiled a list of GDRs for the facility. The IDT team will review these residents and their progress weekly in the IDT meeting, to offer person-center care approaches for any noted behaviors. The Administrator will audit compliance weekly for 12 weeks. The facility's quality assurance performance improvement (QAPI) committee will discuss and audit the findings and offer recommendations regarding the plan. Alleged date of compliance: 11/30/23. The facility's corrective action plan with a completion date of 11/30/23 was validated from 08/28/24 and 09/05/24 by record review, observations and staff interviews. Resident #33's medical records revealed he was sent to the hospital on [DATE] where he received surgical repair for a femoral neck fracture. Review of the 1:1 monitoring tool of Resident #324 started on 11/19/23 and continued through 11/20/23 and was signed by staff to indicate it was done. QAPI meeting held on 11/20/23 and continued to meet monthly for review. Review of the Nurse Practitioner progress note dated 11/20/23 revealed Resident #324 was evaluated for dementia with behaviors. After review the NP determined Resident #324 did not seem to be a threat to himself or others and did not need 1:1 observation. An audit of mobile residents was completed on 11/22/23 and included review of the previous three months of progress for behaviors, the actions taken by staff, and if the provider and responsible party were notified. Review of the in-service education date 11/21/23 titled, Mandatory Abuse Education reviewed of the facility's abuse policy and procedure for investigation of patient abuse, prevention of patient abuse, and review for deescalating behavior techniques. The training included the procedures to identify, correct, and intervene in situations in which abuse may occur and with analysis to included: supervision of staff to identify inappropriate behaviors, deescalating behavioral symptoms, positive approach techniques, and actions to take. The in-service attendance record was signed by department staff including dietary, administrative, nursing, activities, therapy. Attendance was compared to the current list of employees and started on 11/21/23. Review of GDR binder located at the nurse stations contained: pharmacy reviews, medication orders, and GDR recommendations. The binder also included the resident's care profile and person-centered behavior care plan with approaches including redirection distraction, interventions, and triggers related to behavior symptoms with updated approaches. Review of the monitoring tools of residents titled, Behavior Management Program started 11/2023 and continued weekly through 02/2024. Staff interviewed were able to verbalize abuse policy and procedure to identify, correct, intervene abuse and to identify inappropriate behaviors, deescalating behavioral symptoms, positive approach techniques, and actions to take. Observations of the memory support unit revealed staff were engaging and attentive to the residents and used calm and caring approaches to redirect and deescalate potential behaviors and conflict. The completion date of 11/30/23 was validated.