Based on information provided by the complainant, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to attain the highest practicable level of well-being and to prevent and/or manage pain for 1 of 1 sampled resident (Resident #1) who experienced a fall with major injury. Failure to identify circumstances when pain could be anticipated and recognize when the resident experienced pain resulted in Resident #1 experiencing uncontrollable pain related to his untreated hip fracture. Findings include: Information provided by the complainant indicated facility staff failed to identify and respond to changes in the physical status of a resident who experienced uncontrollable pain from a hip fracture sustained during a fall. The complainant also indicated Emergency Medical Services (EMS) staff administered Fentanyl (a medication given for severe pain) during the ambulance ride to the hospital in an effort to alleviate the resident's pain. Review of the facility policy titled Pain Management occurred on 02/16/24. This policy, revised December 2023, stated, . Nurses will assess the resident's pain level . Nurse will complete the following: . Pain assessment, identifying the . factors which increase or decrease pain, nonverbal signs that indicate possible pain, and effect of pain on ADL's. Review of Resident #1's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, vascular dementia, psychotic disorder with delusions, osteoarthritis, repeated falls, and history of left lower leg and right femur fractures. The care plan, dated 12/16/23, identified, . I transfer independently. I need supervision to get to desired locations. Assist me to the bathroom routinely. I take myself to the bathroom and am unable to remember to report having a BM [bowel movement] to staff. A progress note, dated 01/20/24 at 8:15 a.m., identified, . On coming nurse was walking onto the unit and resident was laying on the floor . Resident is unable to tell nursing staff what happened. Evaluation was completed and resident was assisted to feet . vitals were obtained . 0/10 pain [0 pain on 10 point scale], POA [Power of Attorney] was notified . and provider was faxed. The resident experienced a second fall later in the day on 01/20/24. A post-fall huddle tool, dated 01/20/24, identified the following: * Time of Fall 2:50 p.m. * 2:50 p.m., . laying on back . weakness - flu . bruise coccyx . on-call called - push fluids, monitor 4 [for] head injury, give prn [as needed] [medication] for pain for bruising . RLE [right lower extremity] pain . * 3:10 p.m., . Pain 6/10 . RLE WNL [within normal limits] Pain . A progress note pertaining to the second fall identified the following: * 01/20/24 at 4:32 p.m., . Date/Time of Fall . 1-20-24 1350 [1:50 p.m.] [The time entered contradicts the entry the nurse made on the post-fall huddle tool.] Heard a loud noise, Resident found laying [sic] on back with head against the doorframe . Resident has been restless since falling this morning, continues to have flu-like symptoms. Resident assisted up into wheelchair. Resident c/o [complained of] pain to right hip/pelvic area. On-Call provider notified by phone, due to resident hitting head, and being on anti-coagulants [blood thinners]. Provider also notified of increased weakness and pain related to fall. Provider instructed writer to administer PRN pain medication and monitor resident for s/s [signs/symptoms] of head injury. [POA]-Phone call . [Physician] Faxed . * 01/21/24 at 2:33 a.m., . bruising to tailbone area, pain in pelvic/hip area . yells when moved d/t [due to] pain in pelvic/hip area. Bruise noted to tailbone region. Gets very frustrated and angry when trying to help him when needing to change him . * 01/21/24 at 2:50 a.m., . frustrated and irritated when moved . * 01/21/24 at 5:26 a.m., . Staff saying when staff moves him from side to side, he yells out in pain, when he is laying still on his bed or when he moves himself, he denies having any pain. * 01/21/24 at 10:31 a.m., . C/o pain but unable to express where. Resident is still unable to stand without assistance of stand lift. Resident does become agitated and aggressive when staff is assisting. * 01/21/24 at 10:30 p.m., . c/o pain to right pelvic/hip region . continues to c/o of pain to right pelvic/hip region when moving, ROM [range of motion] is limited d/t the pain to the RLE. yells out and gets upset with staff when he is moved . * 01/22/24 at 5:19 a.m., . Reported from day [sic] staff, resident is agitated when being moved or assisted with cares. Resident is able to move RLE on own but ROM is limited when staff is helping him do this. Resident did not receive any pain medication PRN throughout the day. * 01/22/24 at 10:29 a.m., . (R) [right] hip pain and pelvic pain after fall. Pain has continued to worsen and unable to reposition due to pain. updated [Physician's Assistant] when she was here on rounds on 1/20/24 [This date was entered in error.] and she gave orders to transfer to emergency room via ambulance. * 01/22/24 at 10:59 a.m., . Reason for Transfer . increased pain, edema and bruising right hip after fall . * 01/22/24 at 2:17 p.m., . Resident presenting with uncontrollable pain with movement of LE [lower extremity]. Noted edema RLE from the hip to the knee. Resident unable to bear weight due to increased pain. 9/10 pain limited ROM on RLE, increased pain with movement of LLE [left lower extremity]. * 01/22/24 at 2:40 p.m., . Right hip fx [fracture], admitted to [Hospital] for pain control until resident can be transferred to [another Hospital] for surgical repair. Review of the eMAR [electronic medication administration record] showed Resident #1 received two doses of as-needed acetaminophen (a medication given for mild pain); the first dose on 01/20/24 at 3:21 p.m. and the second dose on 01/22/24 at 10:23 a.m. Follow-up documentation, dated 01/22/24 at 12:43 p.m., identified the as-needed acetaminophen was ineffective . Pain Scale was: 9 [on 10 point scale]. During an interview on 02/13/24 at 5:20 p.m., an administrative nurse (#1) acknowledged staff failed to identify/respond to Resident #1's verbal and nonverbal signs/symptoms of pain that were indicative of a possible hip fracture. The administrative nurse (#1) indicated staff felt these signs were related to his flu-like symptoms, weakened condition, and bruised tailbone. Resident #1 experienced uncontrollable pain when facility staff failed to: * Identify circumstances when pain could be anticipated: when Resident #1 was rolled side-to-side, repositioned, and/or bearing weight, * Recognize when Resident #1 experienced pain: when Resident #1 denied being in pain while lying still, but was frustrated, irritated, angry, agitated, aggressive and/or yelling out in pain while being moved, * Identify Resident #1's inability to perform ADLs: when Resident #1 showed limited ROM and his status changed from ambulating independently to requiring a stand-lift and/or being changed by staff, and * Follow-up with the on-call provider regarding Resident #1's verbal/nonverbal signs/symptoms of pain that were indicative of a possible hip fracture versus waiting for the nurse practitioner to make her scheduled rounds.

Based on record review, review of facility policies/procedures, review of the facility's investigation reports, review of quality assurance and process improvement (QAPI) audits, and staff interviews, the facility failed to ensure freedom from abuse/neglect for 1 of 1 sampled resident (Resident #1) with a facial injury sustained while residing in the facility. Failure to provide necessary services to protect residents from harm resulted in Resident #1 sustaining pain, facial bruising, and fear after being slapped by a staff member. Findings include: Review of the facility policy titled Abuse, Neglect, and Exploitation and Misappropriation of Resident Property occurred on 01/31/23. This policy, revised date 01/23/23, stated, . All residents at [name of facility] have a right to be free from abuse, neglect, misappropriation of property, and exploitation. No resident shall be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, . Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, . Physical abuse includes, but is not limited to hitting, slapping, . Review of Resident #1's medical record occurred on 01/31/23. The progress notes contained the following: * 01/19/23 at 7:15 a.m. During medication pass around 0530-0600 [5:30 a.m. - 6:00 a.m.] this nurse heard resident hollering in his room, get out and leave me alone. Upon entering res [resident] room, a CNA [certified nurse assistant] was noted to be kneeling down in front of resident trying to help him put his pants on. Resident was noted to be sitting in his wheelchair with his underwear at his knees and he was not wearing his oxygen at this time. The resident was hollering out that the CNA hit him across the face and knocked his glasses off. This nurse tried to reassure resident that the staff were only here to help him; in which the resident continued to holler out get him out of here! and he hit me, I want to call the cops, right now!. The CNA was then immediately sent out of the residents' room and told to not come back to his room again. Despite all this nurses' efforts, resident could not be calmed down therefore a different CNA was brought into the room to help deescalate the situation and finish getting the resident ready for the day. While in room with CNA, it was noted that resident had a new skin tear to the left ring finger and new bruising across the left side of face extending to left ear. Bruising to face was not noted to be there during medication pass the evening before. * 01/19/23 at 11:22 a.m. PT [physical therapy] Session - [name of resident] says he is not feeling well enough to do therapy this morning. He still has ringing in his ear since last night. Will check back again tomorrow. * 01/19/23 at 4:00 p.m. saw resident's call light on and went to answer it. When asked what he needed, he said he wanted to talk with someone about what happened during the night. The resident went on to ask this author who I was. I told him and he asked what authority I had. He said 'Someone came in telling me to do stuff, throwing his weight around- trying to be the boss, I told him to get out.' 'He hit me and knocked my glasses off.' 'Lucky they weren't broken.' This author asked him to describe who slapped him and he said 'I can't, what do you expect when someone hits you in the eye?' The resident said maybe he said something to make the staff mad, but he couldn't remember what. 'He hit me first, but I tried to hit him back.' . 'I don't want to be here tonight if that staff is here.'. * 01/19/23 at 4:30 p.m. Resident was self-propelling himself down the hallway and told staff he wanted to talk to someone in charge. He said, 'I am scared to go in my room because that man might come in, . * 01/19/23 at 5:03 p.m. skin assessment completed. Noted bruising to lt [left] side of face. bruising measures on lt cheek 1) 2.3 by 3.8 2) 2 by 5.5 3)1.4 by 5.5. 4) Bruising closer to nose next to number 1 measures 3.7 by 3. 5)on res lt ear 3.5 by 3 6) behind rt ear on head 2.9 by 1.4. [record failed to identify the measurement units] * 01/20/23 at 5:15 p.m. [name of nurse practitioner] called after her office visit with [name of resident] . She also reported the resident report of being slapped by a staff member and of being thrown around. * 01/21/23 at 7:39 a.m. Resident was calm and quiet the whole NOC. [night] He refused to sleep on his bed and opted to sleep on his recliner. Resident denies pain on the bruise on his left cheek and made a comment to this nurse Do you see what that guy did? He left quite a mark there. * 01/22/23 at 2:28 a.m. Resident has been in and out of nurses station agitated and looking for help. He states he needs someone to watch his back and requested staff check on him every hour. Staff agreed and this seems to have calmed him down. Resident rested in his bed the rest of the NOC. A skin assessment, completed 01/20/23, identified, .Skin Issue #4 Bruising . L [left] cheek, multiple bruises (handprint) . A provider visit note, dated 01/20/23, stated, . asked what happened to his face and why he has bruising and he states that 'the man working during the night slap [sic] me in the face so hard that it disturb [sic] my hearing for awhile'. administration and director or nursing aware of this incident. During an interview the morning of 01/31/23, an administrative team member (#1) stated staff informed her of the incident at approximately 9:00 a.m. the morning of 01/19/23, and the facility immediately initiated their investigation of the alleged abuse. Based on the following information, non-compliance at F600 is considered past non-compliance with a correction date of 01/26/23. The facility addressed the corrective action accomplished for the resident affected by the deficient practice as evidenced by the following facility actions: - 01/19/23 the facility staff completed the following: * At 7:35 a.m. the charge nurse documents in the progress notes: . Plan of Action: That particular staff member is to not enter residents' room at any given time. Reassurance will be given to resident when needed. Monitoring of resident will continue. * At 9:00 a.m. the Director of Nursing (DON) and charge nurse interview Resident #1. * At 9:30 a.m. the initial allegation of mistreatment, abuse, neglect, or theft facility reported incident reporting form completed and sent to the State Agency. * At 1:15 p.m. the Valley City Police Department (VCPD) informed of the allegation of abuse, and at 2:00 p.m. an officer from the VCPD along with the facility administrator interviewed Resident #1. * At 1:40 p.m. members of the management staff began interview with staff members. * At 5:05 p.m. members of the management staff interviewed the accused CNA. - 01/20/23 during the daily morning meeting via zoom, the leadership staff and risk management staff discussed the 01/19/23 incident and reviewed the abuse policy. * Members of the management staff continued with staff interviews. - 01/23/23 the management staff completed revisions to the policy titled, Abuse, Neglect, and Exploitation and Misappropriation of Resident Property. All staff required to review the revised policy, sign, and date upon completion of review. Review of staff education revealed staff signed and dated, acknowledging review of the policy. - 01/26/23 CNA education meetings held at 7:30 a.m., 2:00 p.m., and 3:30 p.m. to review topics of ADL (activities of daily living) charting and abuse. Review of staff education revealed staff signed the attendance rosters for each meeting. * Review of QAPI audits related to resident abuse showed a facility audit form titled QA Resident Abuse. The audit form contained the definitions of several types of resident abuse and interview questions specific to identification of signs of abuse, reporting, who to contact, etc. The facility completed one to five audits per day on the following dates, 01/19/23, 01/20/23, 01/23/23, 01/24/23, 01/25/23, 01/30/23 and is ongoing.