**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the North Dakota Resident Rights Resident Guide, and resident, staff, and family interviews, the facility failed to respect the resident right to have visitors of their choosing and at the time of their choosing for 1 of 1 sampled resident (Resident #136) and 1 supplemental resident (Resident #96), a married couple whose visitation was discontinued due to behaviors and ended in one resident transferred to another facility. Failure to ensure visitation rights are respected may have been the cause and/or increase of behaviors and/or emotional distress, which negatively impacted the psychosocial well-being of both residents. Findings include: Review of the North Dakota Long Term Care Ombudsman Program Resident's Rights Guide, dated 08/01/19, stated, . You have the right to visitors . with people of your choosing . - During an interview on 10/23/23 at 1:15 p.m., Resident #136 voiced concerns her husband, (who resides at the facility on another unit) has not been allowed to visit her and stated, . I just grieve for him. I just want to see my husband. They took my phone away a couple days ago so now I can't even call [Resident #96], or my sister or my son who both live out of the state. Review of Resident #136's medical record occurred on all days of survey and included a diagnosis of dementia. The Minimum Data Set (MDS), dated [DATE], identified a brief interview for mental status (BIMS) score of 11 (indicating moderate cognitive impairment). Resident #136's progress notes included the following: * 10/03/23 at 10:15 a.m. Resident was observed expression [sic] verbal aggression to staff members during an unexpected visit with her husband. Upon receipt of medications administered to the resident, she responded. 'do not talk to my husband, you're just going to take him away, I do not want your help, I don't even want you to look at him, just go away!' . Resident was observed telling her husband, 'Don't go with her [Resident #96]! She only wants to keep us apart! Don't listen to her!!' The husband had willingly began to leave at this point, even though the resident had a hold of his arm with her hand, and with encouragement from staff, was able to equip his walker and be successfully escorted to the wing which he resides. Upon return, our resident presented with irritability, yelling at another resident to stop something across the room . * 10/12/23 at 3:37 p.m. SS [social service worker] also informed [daughter's name] of the repetitive phone calls [Resident #136's] had been making to the facility's [sic] nurses stations, and explained the necessity to have these lines available for incoming/outgoing calls. [daughter's name] stated, 'My only worry with removing mom's phone is that she won't be able to connect with her sister.' SS assured [daughter's name] that each unit has a cordless phone that can be used for [resident's name] to visit with her sister, and FaceTime can also be initiated. * 10/14/23 at 6:53 p.m. Resident received a visit from her husband at 1800 [6:00 p.m.], which is outside of the agreed scheduled times. Husband requested to have his wife accompany him outside of the unit to another floor in which an activity was occurring (BINGO). Husband was soon accompanied by his primary CNA [certified nurse aide] who attempted to reason and convince husband and that he was not allowed to visit his wife during this time, nor was he allowed to remove her from the unit. Husband began to exhibit frustration with the situation, in which the [floor Resident #136 resided on] nurse intervened to briefly explain that d/t [due to] policy and the program in place for his wife and her safety, she would not be able to accompany him to BINGO. [Resident #136] was present during the discussion and was peaceful and compliant, reminding [husband] that she would not be allowed to leave. Staff nurse offered to allow [husband] to remain on the unit and participate in the activity occurring where his wife lives, but [husband] left, visibly upset, without aggression and outburst. staff assisted [Resident #136] with phone calls to [husband] later and throughout the evening, in which he even returned briefly to deliver her a cookie and report that he had won multiple games of BINGO, then proceeded to peacefully return to his room . * 10/16/23 at 11:23 a.m. [The residents' daughter] returned SS's call at this time, and participated in conversation held with SS and UM [unit manager] for both [Resident #136] and her husband, [Resident #96]. IDT [Interdisciplinary Team] on the call explained the efforts that have been put forth to allow meaningful visits between [Resident #136] and her husband. Further explanation was provided on some of the behavioral symptoms that have been displayed during these visits, and the possibility that potential emotional abuse may be present. Potential discharge planning was discussed at this time. * 10/16/23 at 5:41 p.m. resident became upset when husband went to go back to his unit and grabbed his arm and left a red mark . redirected educated and [sic] visiting hours . husband did leave unit and go to his unit . * 10/17/23 at 9:12 a.m. SS stopped by to check in with [resident] at this time. When SS approached [resident], she was dialing a number on the phone. SS informed [resident] that her husband had just sat down to eat breakfast. SS assured [resident] that staff will assist [husband] back to his room to call her when he is through with his meal. [resident] asked SS, 'well what am I supposed to do then just sit here and wait?' SS inquired about [residents] interests/hobbies, and asked what she would like to do while she waited for her husbands call. [resident] responded it really doesn't matter, I will just wait for [husband's] call. * 10/18/23 10:47 a.m. Note Text: Resident received a phone call from her son via the nursing station. Son [son's name] inquired upon whether resident's phone had been removed from her room and why, in which nursing staff replied generically, 'I will have to inquire within the notes we have butshe [sic] does not currently have a telephone in her room, it might be getting repaired.' Son requested to speak to resident, nursing staff obliged, but remained near to observe the communication between resident and family member, and the behavioral effect on resident. Resident was observed repeating 'I will continue to behave but [husband] is being a bad boy, not following the rules. I am following the rules, but [husband] must not want to comply with the rules!' The phone call appeared to disrupt resident's mood, as she became persistent about contacting her husband, while stating, 'this isn't fair, I haven't done anything wrong!' After a brief conversation with the nurse on staff, who attempted to reassure the resident kindly, and gently, that the staff members are available to provide support in ways that maintain her safety and comfort, they are not provided information as to why the situation is currently, nor are they able to provide resources that give her increased contact with her husband. Redirection and compassion was provided frequently throughout the conversation, but was unwelcomed by the resident, as it was stated by the resident that staff response was 'not what she wanted to hear' adding that 'this is all just a joke' to [everyone]. * 10/18/23 at 4:04 p.m. SS and UM placed a call to [daughter], to discuss discontinuing [Resident #136] phone service at this time, due to frequency of calls placed to the facility's nurses stations. as well as [Resident #136] fixation on the phone. SS assured [daughter] that a weekly FaceTime call can be initiated for [Resident #136] to connect with her sister. * 10/20/23 at 1:02 p.m. SS and UM visited with [Resident #136's] daughter [daughter's name], and son, [son's name] to provide update on previous conversations held with [daughter]. IDT members reiterated staff's efforts to allow meaningful visits between [Resident #136] and her husband. SS informed [son] of behavioral symptoms that have been displayed during these visits, including yelling at each other, as well as arguing with each other, staff and other residents. SS discussed instances where potential physical abuse was also present, as well the events that take place when staff attempt to assist [husband] off of the unit. Potential discharge planning was further discussed at this time. Both [daughter] and [son] stated, We would hate to see mom and dad in separate facilities. *10/21/23 at 5:30 p.m. resident had a zoom call with husband and they talked for about an hour, after getting done she started asking when she could see him in person, why are we keeping him away, I just want to see him in person make sure he is alive. * 10/23/23 at 3:36 p.m. [Resident #136] was on a phone call with her husband. [Resident #136] started to become very agitated and started yelling at her husband. Calling him 'Stupid' . Name of Representative notified: [Daughter]- stated she would still like them to have phone calls . *10/24/23 at 1:22 p.m. Resident was anxious about how her husband was doing and she wanted to call him. After calling him she was still nervous so nursing staff checked in with her husband and updated [Resident #136]. [Resident #136] was able to relax and participated in group exercise and lunch with no further issues. * 10/25/23 at 6:13 p.m. Resident told staff that she 'is grieving for [husband] and I am at the end of my rope!' Resident is upset about her husband and when talking to her daughter she stated, 'I don't think [husband] loves me and I have never been verbally abusive to [husband]. We never fight!' Resident is upset and tearful when talking with daughter. - Observation on 10/25/23 at 4:54 p.m. showed Resident #96, a social service designee (#4), and a CNA (#6) stood outside of the door to the memory care unit where Resident #96's wife (Resident #136) resides. The CNA (#6) stated, The door is locked [Resident #96] we've tried it a hundred times already. We can't get back there. The social service designee (#4) stated, [Resident #96] there is no visitation on that unit now. We can't go back there. The resident remained calm and spoke in a soft voice with head held down. His body language suggested potential sadness/disappointment related to not being allowed to visit his wife. At 4:58 p.m., a licensed social worker (LBSW) (#5) arrived and attempted to remove Resident #96 from the doorway telling him he could not visit his wife. The resident had a cupcake on his walker he wanted to give to his wife. When the surveyor asked the staff members (#4, #5, and #6) why the resident couldn't visit his wife, the staff members stated they did not know and would have to get back to the surveyor with the information. At 5:04 p.m., Resident #96 stated to the surveyor, They [staff] tell me I can't see my wife, and she's never done anything wrong. We've been married over 50 years, and we both love each other very much, and I'm proud of that. At 5:08 p.m., the social services designee (#4) reassured the resident she would personally take him to see his wife (Resident #136) after supper. During this conversation the resident showed increasing signs of frustration/anxiety, but reluctantly agreed to go to a private area and sit down. Review of Resident #96's medical record occurred on 10/26/23. The MDS, dated [DATE], identified a BIMS score of 15 (indicating cognitively intact). Resident #96's progress notes included the following: * 09/01/23 at 3:28 p.m. Social Services found resident in his room attempting to cut off his wander guard with a nail clipper. resident was noted saying 'I want to go visit my wife and the policy of the place doenst [sic] let me'. * 09/11/23 at 10:18 p.m. [Resident #96] visited wife outside of care planned timeframe and interrupted cares as reported by community life aide . Staff assisted [Resident #96] from the unit, to which he reportedly resisted by yelling at staff. * 10/04/23 at 2:20 p.m. SS spent time visiting with [Resident #96] in regards to his wife's placement on the memory care unit. (20 minute conversation). resident voiced he would like for his wife to be moved off of the memory and stated, 'I had no idea she was in a locked ward. She really doesn't need all of that.' SS provide reassurance to [Resident #96], and explained that his wife's placement is appropriate to best meet her needs. * 10/10/23 at 8:30 p.m. Patient went to visit his wife on separate floor within SNF [skilled nursing facility] and refused to leave when patients were being prepared for bed. Patient had to be told several times by charge on floor [unit's name] that he needed to return to his home floor. * 10/11/23 at 6:57 p.m. Charge Nurse was requested to separate floor [unit's name] to assist with escorting resident off unit, due to staff preparing for bed. Charge Nurse required therapeutic talk to console resident as he was attempting to remove another resident (wife) from [unit's name]. Charge Nurse additionally explained resident could visit with wife in the morning 10/12/23 and also provided that residents can speak to each other through via telephone. Resident although reluctant at first did comply. * 10/16/23 at 4:44 p.m. SS and UM for [Resident #96] and his wife called daughter [daughters name] at this time and date. IDT members on the call explained the efforts that have been put forth to allow meaningful visits between [Resident #96] and his wife. Further explanation was provided on some of the behavioral symptoms that have been displayed during these visits, and the possibility of that potential emotional abuse may be present. Potential discharge planning was discussed at this time. * 10/16/23 at 4:57 p.m. Visitations between [Resident #96] and his wife suspended as a behavior intervention . [Daughter] thanked writer for call and SS for update and expressed understanding. * 10/24/23 at 5:24 p.m. SS placed call to [daughter] to review placement preferences. [Daughter] voiced preference for VA (Veteran's affair) contracted facilities. * 10/25/23 at 5:55 p.m. SS placed call to [daughter] regarding transfer to [facility name]. [Daughter] voiced understanding of the room move. The medical records for Resident #96 and Resident #136 showed two progress notes regarding physical abuse: - 03/15/23 (Resident #136 scratched Resident #96) - 10/16/23 (Resident #136 grabbed Resident #96's arm during a visit leaving a red mark on Resident #96's wrist) documented potential emotional abuse in each medical record. After the 10/16/23 incident the medical record showed an order for a psychiatric referral on 10/25/23, and the initiation of a medication for mood on 10/19/23 for Resident #136. - Instances of verbal abuse between the residents were noted with documentation of redirected/reapproached by staff with family in agreement of interventions. During an interview on 10/25/23 at 5:09 p.m., a LBSW (#9) verified visitation between the couple had stopped last week due to concerns of emotional abuse during the residents' in-person visits. Prior to the stop of visits facility staff had set up scheduled visits three times a day. One incident occurred when Resident #136 grabbed onto Resident 96's arm and didn't want to let go. Also, Resident #96 would become upset when Resident #136 would not remember things. The LBSW denied the facility initiated the no visitation between the couple and stated, The residents' family suggested no visitation. During an interview on 10/25/23 at 5:34 p.m., an administrative staff member (#13) denied the facility initiated the no visitation between the couple and stated the residents' family suggested no visitation. The staff member identified all the documentation for [Resident #96 and Resident #136] is noted in progress notes, and offered no further documentation to the survey team. During an interview on 10/26/23 at 11:13 a.m., two administrative staff members (#7 and #8) stated the family had suggested visitation stop between Resident #96 and Resident #136 to keep them safe, stating Resident #96 has been physical. During a phone interview on 10/26/23 at 11:37 a.m., Resident #96 and Resident #136's daughter (Power of Attorney) stated, I did not suggest they stop visitations. Our [her and brother's] hope would be for them to be in the same building and see each other at least occasionally. When asked if she was aware of a possible discharge for her dad [Resident #96] the daughter stated, Yes, they have discussed moving him [dad] to [another facility] with me because dad figured out the code to the memory care unit where mom is. The daughter went on to say the facility had suggested supervised visits only when the family is present, however, the daughter stated that was not possible for her to be present at the facility to meet all the visitation needs of her mom and dad. This interview contradicted staff interviews regarding who initiated no visitation between Resident #96 and Resident #136. The facility failed to ensure continued alternative options/interventions were offered for visitation to maintain the residents' personal relationship and the family's verbalized hopes for their parents to remain in the same building. The facility action to discharge Resident #96 (family agreed to facility-initiated transfer/discharge) further limited the right to reasonable access for visitation.