**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of a Self-Reported Incident (SRI), review of witness statements, resident interviews, staff interviews, review of the police report, review of facility fall incident reports, and review of the facility polices for Behavioral Health Services, Unmanageable Residents and Behavioral, Assessment, Intervention and Monitoring, the facility failed to ensure Resident #203, who had a history of behaviors, was provided an effective and individualized plan of care to address how staff would provide care and treatment safely and/or interventions to address behaviors when the resident was displaying behaviors. This resulted in Actual Harm on 07/01/23 at approximately 9:00 P.M., when Resident #203 sustained an acute, nondisplaced humeral fracture during care by State Tested Nursing Assistant (STNA) #515. While STNA #515 was providing personal care, Resident #203 exhibited signs of agitation, aggression, and combative behaviors, however the STNA failed to address the behaviors, failed to stop providing care and reproach and/or provide care in a safe and non-threatening manner. As the STNA continued to provide care, Resident #203 was yelling out expletive words and stop that hurts. The STNA failed to stop until care was completed. This affected one Resident (#203) of three residents reviewed. The facility census was 54. Findings include: Review of the medical record for Resident #203 revealed an admission date of 01/04/23. Diagnoses included infection and inflammatory reaction due to internal left knee prosthesis, type II diabetes mellitus with stage III chronic kidney disease, methicillin resistant staphylococcus aureus, catatonic schizophrenia, and schizoaffective disorder. Review of Resident #203's care plan initiated on 01/13/23 revealed she required one to two staff for care due to frequent behaviors such as yelling out, swearing, swatting at staff, kicks at staff, kicks at bed and wall. The plan of care did not provide parameters for which situations required two staff for care. Resident #203's care plan did not identify all targeted behaviors when the resident became combative with care, there were no person-centered interventions to provide safeguards for the resident when displaying combative behaviors or to identify interventions for staff to utilize to ensure resident and staff safety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #203 revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Review of activities of daily living (ADLs) section of the MDS revealed the resident required extensive assist of two staff for bed mobility, dressing total dependence of two staff for transfer, toileting, personal hygiene, bathing, total dependence of one staff for locomotion on unit, and supervision of one for eating. Resident #203 was noted to be incontinent of bladder and frequently incontinent of bowel. Resident #203 was assessed to be short tempered and easily annoyed almost daily and exhibited physical and verbal behaviors one to three days of the review period. Review of Behavior Symptom monitoring from 06/08/23 to 07/07/23 for Resident #203 revealed she was being monitored for behaviors daily. Resident #203 was noted to exhibit daily behaviors including yelling, kicking/hitting, grabbing, biting, abusive language, threatening behavior, and rejection of care. Review of the nurse progress note dated 07/01/23 at 9:24 P.M., revealed Registered Nurse (RN) #549 was outside of Resident #203's room when she heard the resident yelling. RN #549 approached Resident #203 and asked what wrong and Resident #203 stated her left arm was hurting. RN #549 asked for clarification on where exactly her arm was hurting. Resident #203 stated, the whole arm, and then clarified it was the elbow. No redness, swelling, bruising or obvious deformity noted at time of assessment. Medical Doctor (MD) #570 was notified of new onset of pain. An as needed (PRN) analgesic was administered, and guardian was notified. Review of radiology report dated 07/02/23, performed at 12:26 P.M. and reported at 12:50 P.M., for Resident #203 revealed an acute, transverse, nondisplaced epicondylar fracture of the distal humerus. The proximal radius and ulna appeared intake. No significant joint effusion. Mild soft tissue swelling. Severe atherosclerosis. Review of the facility SRI dated 07/02/23 and timed 5:04 P.M., revealed the facility noted an injury of unknown injury related to resident complaining of pain, which was not normal for Resident #203. Resident #203's x-ray results revealed a to a distal humerus fracture. The facility unsubstantiated any evidence of abuse. Review of the witness statement provided by Assistant Director of Nursing (ADON) #573 revealed she called LPN #574, and she was in Resident #203's room at the time. ADON #573 requested to speak with Resident #203 and LPN #574 held the phone for Resident #203. ADON #573 asked Resident #203 if she was able to tell her what happened to her arm. Resident #203 stated, it hurt. ADON #573 proceeded to ask her when it began hurting and Resident #203 stated late last night and further stated STNA #515 (identified by name) pulled on it. ADON #573 asked Resident #203 what STNA #515 was doing and Resident #203 stated, she was changing me. ADON #573 asked Resident #203 if another staff was present and Resident #203 stated, she was alone. Review of witness statement dated 07/02/23 from STNA #515 revealed while she was changing Resident #203, she began reaching back and hitting her. STNA #515 stated she asked Resident #203 to stop, and it got worse and when STNA #515 pulled Resident #203 towards her to untuck her brief from the other side, Resident #203 grabbed her right arm and scratched her. Resident #203 continued to kick and swing and hit STNA #515 as she pulled her up in the bed. As STNA #515 was leaving the room, Resident #203 was telling her to (expletive word) off, (expletive word)! and called her (expletive word)! STNA #515 stated she knew nothing about Resident #203's arm or her having pain until STNA #536 asked her what happened because RN #549 has asked STNA #536 about what happened. STNA #515 stated RN #549 did not ask her what happened. Review of police report #22307007 dated 07/02/23 timed at 7:43 P.M., for Resident #203 revealed Police Officer (PO) #571 was dispatched to the local hospital due to RN #571 reporting Resident #203 stated STNA #515 pulled her arm out of place while she was changing her at Regency Care of [NAME] (which is now called Tranquility of [NAME]). There was no mention of Resident #203 having stated she had a fall. Based on the police investigation, nothing criminal was identified. The alleged perpetrator reported having to hold Resident #203 down to finish care, but no further description was described. Interview on 07/05/23 at 2:40 P.M., with RN #549 revealed on 07/01/23 at around 9:00 P.M., State Tested Nurse Aide (STNA) #515 went into Resident #203's room to provide care. Resident #203 yelled out, Stop you (expletive word)!. RN #549 stated she was passing medications and since Resident #203 yells out frequently during care she did not think it necessarily unusual. RN #549 continued to pass medications and then heard Resident #203 yell out in pain again, It hurts you, (expletive word). RN #549 stated she went in to investigate since Resident #203 does not usually yell out in pain. Resident #203 stated her entire left arm hurt. RN #549 lightly touched different points on Resident #203's arm but did not see any visible bruising or obvious deformity. Resident #203 stated her left elbow hurt and agreed to take pain medication. RN #549 contacted MD #570 and obtained an order for a STAT x-ray. RN #549 confirmed she was not aware of any other staff in the room with Resident #203 other than STNA #515. RN #549 stated Resident #203 was a two-person transfer and one to two staff for care due to the resident's history of combativeness. RN #549 confirmed she did not ask Resident #203 what happened and did not ask staff for witness statements. Interview on 07/05/23 at 3:29 P.M., with STNA #530 revealed on 07/02/23 around 7:10 A.M. she entered Resident # 203's room with STNA #531 to provide care for both Resident #203 and #204. While STNA #530 was washing Resident #203's face, she moved the pillow by Resident #203's left arm and she immediately screamed out that her left arm hurt. STNA #530 stated she noticed a small bruise just above the left elbow. STNA #530 asked Resident #203 what happened and Resident #203 screamed the name, STNA #515 (identified by name). STNA #530 asked Resident #203 about what happened, Resident #203 stated, STNA #515 (identified by name) yanked on my arm. STNA #530 went to go get Licensed Practical Nurse (LPN) #574. LPN #574 stated she was aware of the order for the x-ray and proceeded to evaluate her and stated she was waiting for the x-ray to be completed. STNA #530 stated she and STNA #531 finished changing the resident and kept her in bed and did not move her. STNA #530 stated she asked Resident #203's roommate (Resident #204) about what happened and Resident #204 stated staff had been aggressive with Resident #203 but she was not able to see because the curtain was pulled. After lunch the x-ray revealed a fracture and LPN #574 notified the Director of Nursing (DON). Interview on 07/05/23 at 4:40 P.M., with STNA #531 revealed on 07/02/23 around 7:00 A.M. she was in changing Resident #204 while STNA #530 was assisting Resident #203. When STNA #530 removed the pillow from underneath her left arm, Resident #203 cried out in pain. STNA #530 asked for assistance from STNA #531 and when they rolled Resident #203 over to change her, she again cried out in pain. After STNA #530 and #531 finished cleaning her up, they asked her what happened and Resident #203 replied, STNA #515 (identified by name). When STNA #530 and #531 asked Resident #203 about what happened she stated, she yanked my left arm. Resident #203's roommate (Resident #204) stated she heard night shift being rough with Resident #203. Initially, Resident #204 stated it was just STNA #515 in the room but then later stated, them but was unsure if another staff member was in the room since the curtain was pulled. Resident #204 stated she heard Resident #203 tell staff, Stop! You are hurting me! STNA #530 and #531 told LPN #574 and she proceeded to assess the resident. A telephone interview on 07/05/23 at 5:05 P.M., with STNA #515 revealed she went in to assist Resident #204 (Resident #203's roommate) to get her up to smoke around 9:00 P.M. on 07/01/23. RN #549 was in the room passing medications to Resident #203 and RN #549 told STNA #515 Resident #203 had removed her brief. After STNA #515 finished with Resident #204, she proceeded to assist Resident #203. STNA #515 stated she got supplies to clean Resident #203 up and proceeded to roll Resident #203 onto her right arm towards the wall to clean her up. Resident #203 began swinging at her. STNA #515 stated Resident #203 hit her (STNA #515) in the face and scratched her right arm. STNA #515 stated she finished changing Resident #203 and left the room. STNA #515 stated RN #549 did not ask her what happened, but asked STNA #536 about what happened with Resident #203. Around 11:00 P.M., STNA #515 stated she was sitting at the nurses' station with STNA #536, and STNA #537 and saw an order for an x-ray for Resident #203. STNA #537 asked RN #549 why Resident #203 needed an x-ray and RN #549 stated Resident #203 was complaining of pain to her left arm, but was not accusing STNA #515 of foul play and just wanted to be safe. STNA #515 stated she received a call from Police Officer (PO) #571 on 07/02/23, who informed her of Resident #203's left elbow fracture. STNA #515 stated PO #571 told her Resident #203 stated she fell out of bed and that was how she injured her arm. STNA #515 stated Resident #203 did not fall out of bed while she was working with her on 07/01/23 and had not mentioned a fall to her during her shift. Interview on 07/05/23 at 5:29 P.M., with Resident #204, the roommate of Resident #203, revealed she was in the room when STNA #515 was providing care to Resident #203. The curtain was pulled, and she heard Resident #203 scream loudly, which was sometimes normal, but this time was very different. Resident #204 stated it sounded like extreme pain. Resident #203 stated to STNA #515, You are hurting me, you (expletive words)! and said it multiple times. Resident #204 stated STNA #515 continued to provide care. Resident #204 stated STNA #515 said, Shut up, we're not hurting you. When asked if there was another staff member in the room, Resident #204 stated she was unsure because the curtain was pulled. Interview on 07/06/23 at 6:35 A.M., with STNA #519 revealed she asked Resident #203 what happened during the night shift of 07/01/23. Resident #203 stated she didn't want to say. Resident #204 (Resident #203's roommate) stated she was asleep and woke up to them fighting. She stated STNA #515 was arguing with Resident #203 and was holding Resident #203's arms and Resident #203 began screaming loudly. Resident #203 stated Resident #203 yelled out in pain. Resident #204 stated she could see STNA #515 from her bed because of the mirror on the opposite of the room across from her bed even though the curtain was pulled. Interview on 07/06/23 at 9:25 A.M., with the Director of Nursing (DON) revealed he became aware of this incident on 07/02/23 at around 2:00 A.M., when he read a text from RN #549 which stated Resident #203 was having pain and had been combative while care was being provided by STNA #515. The DON revealed Resident #203 was combative with care at times but does not cry out in pain frequently. On 07/02/23, an x-ray for Resident #203 was obtained and based on those results, she was sent out to the hospital for further evaluations. The DON stated around 5:00 P.M. on 07/02/23, the facility opened a self-reported incident (SRI), and they obtained witness statements from the staff. The DON stated he was not aware of any previous concerns related to STNA #515 and did not believe abuse had occurred. The DON stated STNA #515 told him Resident #203 had fallen a few days earlier, but he was not aware of any fall incidents prior to the injury noted on 07/01/23. The DON confirmed there was not a fall incident listed on the facility incident report around the time of the incident nor over the past month involving Resident #204. Review of the facility fall incident reports revealed Resident #203 had not had a documented fall in the past 30 days. Interview on 07/06/23 at 11:03 A.M., with Resident #203 revealed on 07/01/23 during the evening shift, STNA #515 was changing her brief and pulled on her arm and it hurt. Resident #203 confirmed this had not happened before. Resident #203 declined to speak further about the incident. Observation at the time of the interview revealed Resident #203 had a flat affect and her was voice was monotone while answering. Follow up interview on 07/06/23 at 1:05 P.M., with Resident #203 revealed falling out of bed was not how she was injured, and she did not want to speak about it further. Observation at the time of the interview with Resident #203 revealed she had a flat affect and she spoke with a monotone voice. Follow up interview on 07/06/23 at 2:25 P.M., with STNA #515 revealed around 9:00 P.M. on 07/01/23 she responded to the call light for Resident #204 to get up to go smoke. RN #549 was already in the room giving Resident #203 her medications and proceeded to tell STNA #515 Resident #203 had removed her brief. After finishing with Resident #204 she proceeded to assist Resident #203. STNA #515 gathered water and a soapy cloth to clean Resident #203 up before putting on her brief. STNA #515 rolled Resident #203 onto her right side towards the wall to clean her bottom. Resident #203 began flailing and hitting her. Resident #203 attempted to hit STNA #515, and she attempted to block her with her own arm and Resident #203 scratched her right arm. Resident #203 then rolled back onto her back. STNA #515 stated she already had the brief underneath her tucked in and was able to pull the tab for the brief out of the other side to fasten the brief. While STNA #515 was fastening the brief, Resident #203 was holding STNA #515's right arm and scratched it. When asked about clarification about the statement given to the police officer, STNA #515 stated she did not tell the police officer she had to hold Resident #203 down to finish her care. STNA #515 stated she raised the foot of Resident #203's bed and used the pad underneath her to pull her up. STNA #203 stated she did not have her hands on Resident #203 when pulling her up and stated she was trying to do it herself. When asked if she should have continued to provide care when Resident #203 became combative, STNA #515 stated What was I supposed to do, leave the resident half-changed? STNA #515 stated she did not know where her partner (the other STNA) or the nurse was. STNA #515 confirmed if a resident becomes combative with care, she was supposed to request other staff to assist, and confirmed she did not yell out for help or text for assistance. STNA #515 stated she looked out in the hallway but did not see anyone, so she proceeded to finish. Phone interview on 07/06/23 at 5:50 P.M., with STNA #536 revealed she did not become aware of the incident with Resident #203 until around 10:00 P.M. when RN #549 asked about why Resident #203 was yelling out. Following being asked, STNA #536 proceeded to enter Resident #203's room and found Resident #203 sleeping with her arms behind her head and left the room. Around 12:30 A.M., STNA #515 came to get STNA #536 to assist with changing Resident #203 because her lower half was hanging off the bed. STNA #536 entered the room after STNA #515, and they proceeded to use the sheets from the bed to hoist Resident #203 back into bed. Once Resident #203 was back in bed, they proceeded to change Resident #203 with no complaints of pain. STNA #536 confirmed Resident #203 was not combative when they changed her. STNA #515 told STNA #536 that Resident #203 had been combative with her around 9:00 P.M. and had scratched her arm. STNA #536 confirmed she did not ask Resident #203 what happened to her left arm and Resident #203 never made comments as to what had occurred. Follow up interview on 07/07/23 at 5:40 A.M., with RN #549 revealed she asked Resident #203 where her arm hurt but did not recall asking her how it happened. RN #549 stated she figured since Resident #203 was sometimes combative with care, she may have gotten hurt while being changed, possibly she had hyper-extended it, if she tried to swing at the aide. After talking with MD #570, he gave an order for a STAT x-ray to be completed. RN #549 stated she requested the x-ray just to be safe but did not think it was potentially abuse and did not start an investigation. RN #549 attempted to place the STAT order for the -x-ray for Resident #203, but her sign in for the x-ray company did not work. RN #549 stated she called Assistant Director of Nursing (ADON) #573 at 9:15 P.M. and the DON at 9:20 P.M. and informed them Resident #203 had complained of pain and MD #570 had requested a STAT x-ray and she was unable to place the order. ADON #573 asked RN #549 to call LPN #576 to place the order, but she was also unable to complete the order for the x-ray, so she called ADON #573 again around 10:00 P.M. RN #549 finished her med pass around 11:30 P.M.-12:00 A.M. and had still not heard back from ADON #573 or the DON, so she called the mobile x-ray company, and they were able to place the order for Resident #203. The x-ray company had not come when she left at 7:15 A.M. on 07/02/23. RN #549 stated she was told she did not have to write a witness statement because she had already written the nursing progress note. RN #549 confirmed STNA #515 finished her shift as scheduled on 07/01/23. RN #549 stated if she suspected potential abuse, she would separate the employee from the resident and ask the employee to leave immediately, report the incident to the DON, start an investigation immediately and obtain witness statements from all the employees involved and residents, since there is only two hours to report it to the state. Interview on 07/07/23 at 10:09 A.M., with LPN #574 revealed around 12:55 P.M. she checked Resident #203's arm and lifted it and Resident #203 stated, Ow!. Observation at the time, revealed Resident #203's arm to be more swollen and bluish in color, oblong in shape about two inches by one and a half inches left of the antecubital. While LPN #574 was in Resident #203's room she got a call from ADON #573 who requested to speak with Resident #203. LPN #574 held the phone up to Resident #203's ear and ADON #573 asked what happened to which Resident #203 responded that it happened while being turned in bed while she was being changed. LPN #574 stated no additional questions were asked and no additional information was given by Resident #203. When the x-ray results came back, LPN #574 notified ADON #573 who made the arrangements for the ambulance transfer. Interview on 07/07/23 at 10:42 A.M. with ADON #573 revealed while she was on the phone with Resident #203 on 07/02/23 around 1:00 P.M., Resident #203 responded that she was injured while being turned and stated STNA #515 was helping her. Based on that conversation, ADON #573 stated the facility opened a self-reported incident (for an injury of unknown origin) and began requesting witness statements of anything that may have been out of the ordinary for Resident #203. Phone interview on 07/07/23 at 12:36 P.M., with MD #570 revealed he was informed Resident #203 had probably slammed her elbow into something and thought it from trauma and suspected Resident #203 had osteopenia. Since it was a clean break and not a spiral fracture, he did not suspect abuse. Interview on 07/07/23 at 2:46 P.M., with the Administrator and ADON #573 revealed they were not aware of any disciplinary actions related to STNA #515. The Administrator stated they were not informed by the hospital of any suspected abuse. The police officer showed up at the facility on 07/07/23 at 9:06 P.M. and was referred to the DON. Interview on 07/07/23 at 3:37 P.M., with the DON revealed he spoke on the phone with Police Officer #571 who stated he did not suspect anything related to abuse and stated the nurses at the hospital had stated they did not feel the injury was a result of physical abuse, but stated it was customary to report to the police for investigation. The facility had started the SRI investigation after receiving the x-ray results for Resident #203 and proceeded under injury of unknown origin. Based on the investigation and witness statements, they did not feel there was definitive proof of the cause of Resident #203's fracture. Review of the policy titled Behavioral, Assessment, Intervention and Monitoring revised 2016, revealed interventions and approaches would be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for behavior, targeted and individualized interventions for the behavioral and psychosocial symptoms, rational for the interventions, specific an measurable goals for behaviors and how the staff would monitor for effectiveness of the interventions. Review of the policy titled, Unmanageable Residents dated revised April 2010, revealed should a resident's behavior become abusive, hostile, assaultive, or unmanageable that would jeopardize his or her safety or the safety of other, the Nurse Supervisor/Charge nurse must immediately provide for the safety of all concerns, notify the resident physician, notify the DON, and notify the representative. Review of the policy titled, Behavioral Health Services dated October 01, 2010, revealed non-pharmacological intervention refers to approaches to care that do not involve medications, generally directed towards stabilizing and/or improving a resident's mental, physical, and psychosocial well-being. The facility would ensure that necessary behavioral health care services were person-centered and reflect the resident's goal for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Facility staff would implement person-centered care approaches designed to meet the individual goals and needs of each resident which includes non-pharmacological interventions. This deficiency represents non-compliance investigated under Complaint Number OH00144212.