**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents did not experience resident to resident abuse for two (#10 and #16) of two residents sampled for abuse. The facility failed to ensure: a. Res #80 did not assault and injure Res #10 and #16. b. Res #10 was assessed for psychosocial harm and interventions were put in place to mitigate the harm after the assault by Res #80. c. a follow up of Res #16 possible brain bleeding caused by the assault by Res #80 was conducted. d. they instituted new interventions to protect the staff, the resident, or other residents when the facility the facility knew or should have known Res #80 was capable of aggressive behaviors towards others and had continued behaviors. The Resident Census and Conditions of Residents form documented 28 residents resided in the facility. Findings: A facility policy, titled Abuse - Reportable Events, revised on 01/2018, read in parts, .It is the responsibility of all facility staff to prohibit resident abuse, neglect, exploitation, and misappropriation of resident's property in any form; and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse, neglect and/or exploitation caused by another person .6. Protection .c. If another resident is the alleged perpetrator, they shall immediately be assessed for treatment options. The safety and protection of other residents is the home's primary concern .7 .c. After investigation, administration will analyze the occurrence to determine what changes, if any, are needed to the policies and procedures to prevent further occurrences . 1. An incident report, titled Incident Report Form, dated 04/12/23 at 12:45 a.m., included a nurse note which documented Res #80 was observed lying in bed and was on 15 minute visual checks for history of climbing out windows. The note documented at 12:50 a.m., a loud noise was heard and Res #80 was banging on the door of Res #16 and a CNA had shut the door of Res #16 to protect them as Res #16 was defenseless. The note documented Res #80 had pulled Res #16 off their bed and on to the floor. The note documented at 12:55 a.m., 911 was notified and the police, fire, and an ambulance had arrived. The note documented Res #80 had poured mouthwash on the police officers and was yelling at them to get out of Res #80's home. The note documented Res #10 came out of their room with multiple skin tears to their arms and stated Res #80 had grabbed their arms and forced them out of their bed. The note documented first aide was provided to Res #10 and the police sat with Res #80 while placement at a hospital with the appropriate psychiatric services were found and transport could be arranged. A police report titled, Incident/Offence Report, dated 04/12/23 at 12:49 a.m., documented a offence of simple assault when a resident became combative to staff members and other residents. The report documented at the time of arrival of the author of the report, Res #80 was sitting at the nursing station and appeared calm. The report documented the nursing staff reported to them Res #80 had pulled Res #10 out of their bed and in the process had injured Res #10's arm. The report documented the officer could see what looked like a piece of missing skin from Res #10's arm. The report documented a witness statement of CNA #1 who had heard Res #16 yelling and went to check on them. The report documented when the CNA entered the room they found Res #16 on the floor and then Res #80 had gone to Res #10's room and assaulted them. The report documented the CNA took Res #10 to Res #16's room to get away from Res #80 and closed the door. The report documented the CNA stated Res #80 was pounding on the door, spraying Lysol at them, and striking them. 2. Res #10 had diagnoses which included anxiety disorder, schizoaffective disorder, insomnia, and recurrent depressive disorder. An annual assessment, dated 09/06/22, documented Res #10 was intact in cognition and required supervision and set up with ADLs. A nurse note, dated 04/12/23 at 5:05 a.m., documented the resident had been in an altercation with another resident. The note documented this resident defended theirself and received multiple skin tears on bilateral arms. A nurse note, dated 04/12/23 at 1:47 p.m., documented after the altercation with the other resident there was now bruising to bilateral lower arms. The note documented the resident had two bruises on the right arm measuring 12.0 x 3.0 cm and another one measuring 2.0 x 3.0 cm. The note documented the resident's left arm had a 20.0 x 3.0 cm injury which was not defined and a 3.0 x 2.0 cm skin tear to the posterior antecubital area with treatment in place. The note documented the resident complained of mild pain and soreness in the shoulder and neck area. Interventions, dated 04/12/23, were added to the resident's care plan for falls and documented an intervention/approach to monitor skin tears for signs and symptoms of infection and for bruising on bilateral upper extremities to treat as ordered by the physician. The care plan entry documented to frequently check the resident through the night to ensure their safety. A progress note from a mental health provider, dated 05/06/23, documented a chief complaint of Establish care for depression. The note documented the resident did not like it in the nursing home. The note documented the resident stated their anxiety was under control with medications and they denied mood swings, new or worsening depression, or night terrors. A progress note from a mental health provider, dated 06/02/23, documented chief complaint of Follow up Schizoaffective. The note documented the resident had anxiety and was worried about their health and was able to sleep with medications. A progress note, dated 06/26/23 at 2:44 p.m., documented the resident was seen by their physician and had complained of anxiety, pain in their feet, and daily headaches. The note documented the physician ordered depakote twice daily for the headaches and increased the resident's dose of trazodone to 75 mg at night. On 07/31/23 at 11:49 a.m., Res #10 was observed in their room lying on their bed. The resident stated they remembered the incident when they was assaulted by Res #80 very well and had not felt safe living in the facility since. The resident stated their fear was getting better but they were very frightened for a long time. The resident recalled the incident when Res #80 entered her room, pulled them up from their bed, and was scratching their arms causing them to bleed. When asked what the facility had done to help them feel safe the resident stated they were told Res #80 would not be returning to the facility. The resident was asked if they went to the hospital after the incident and they stated they had not but wished they had because their neck had bothered them since then. The resident stated they had told the doctor about their neck pain but they did not do anything about it. On 07/31/23 at 12:07 p.m., the administrator was asked if they had conducted an in-service on what to do with this type of resident to resident abuse. The administrator stated they would have to check the in-service book. The administrator was asked if the facility had checked to ensure the residents felt safe after the incident. The administrator stated Res #10 had expressed they did not feel safe at the facility and anytime the door bell rang Res #10 would become frightened and express worry that Res #80 was returning to hurt them. The administrator was asked if the facility had put anything in place to help Res #10 with their anxiety regarding Res #80 and the administrator stated they kept reassuring the resident that Res #80 would not be returning. The administrator asked if the facility had looked into mental health counseling for the resident to help them process and deal with the feelings, and stated not to their knowledge. The administrator was asked if the care plan had been updated to include interventions to help the resident feel safe. The administrator stated not to their knowledge. On 07/31/23 at 12:25 p.m., the administrator and RN #1 provided two copies of mental health notes for Res #10 dated after the incident. The administrator and RN #1 were asked if they had made the mental health professional aware of the event and Res #10's fearfulness. RN #1 stated they were unaware if the mental health professional had been made aware as they were a new service for the facility. RN #1 stated the Res #10 seemed better in June of this year than they were in May after the event when they had been very fearful. The administrator stated they looked though the in-service book and a post incident in-service was not conducted. The administrator stated they had spoken with staff during the stand up meeting on the morning of the incident only and had no documentation on what was discussed. On 07/31/23 at 1:25 p.m., the mental health professional was interviewed by phone and stated they had seen the resident in May and June as part of the resident's regular psychiatric health care. The mental health professional stated they always asked about abuse when starting care for a new client and if it was not documented in their notes it was because the resident had denied abuse occurred. The mental health professional was asked if the facility had told them the resident had been experiencing fearfulness related to an assault which had occurred in April of 2023. The mental health professional stated they had not been notified and it could take several months for a resident to open up about what they were dealing with since this was a new service provider to the facility and only saw clients at the facility starting in May. The mental health provider stated another service had been providing mental health services at the facility before April. 3. Res #16 had diagnoses which included symptomatic epilepsy, traumatic brain injury, schizoaffective disorders, and chromosomal abnormality. An annual assessment, dated 03/12/23, documented the resident was severely impaired in cognition, required extensive to total assistance with most ADLs, had upper extremity impairment on one side and lower extremity impairment on both sides. A nurse note, dated 04/12/23 at 1:15 a.m., documented the resident had been possibly injured in a fall and was sent to the hospital for evaluation and treatment. A nurse note, dated 04/12/23 at 4:40 a.m., documented a nurse from the hospital had contacted the facility for further information on Res #16. The nurse stated the resident had a brain bleed and was being held for observation for six hours and then a new CT would be done. A nurse note, dated 04/12/23 at 10:10 a.m., documented the facility called the hospital and spoke with the ER nurse, who at that time, told the facility it was not a brain bleed but was it was possible bruising and a non emergent MRI would be needed to be set up as an outpatient. A nurse note, dated 04/12/23 12:18, documented the resident had returned to the facility and the CT scans at the hospital had indicated an impression of a small left frontal hyperdensity which may have reflected a small parenchymal bleed. The note documented a follow up was recommended in two weeks. A quarterly assessment, dated 06/17/23, documented the resident was severely impaired in cognition, required extensive to total assistance with most ADLs, had upper extremity impairment on one side and lower extremity impairment on both sides. On 07/26/23 at 3:50 p.m., the administrator stated Res #80 was on every 15 minute observation and when the CNA had last checked on her she was in bed with her eyes closed. The administrator stated the CNA heard a noise and Res #80 had pulled Res #16 out of their bed and onto the floor. The administrator stated the nurse and the CNAs were immediately in the room removing Res #80 from the room and Res #16 was sent to the hospital. The administrator stated Res #16 returned later that day and neuro checks were done on the resident. The administrator was asked if they had any indication the resident may have been physically aggressive before they were admitted to the facility. The administrator stated the family had stated Res #80 had ''sundowners'' but there was no mention of physical aggression at that time. On 07/31/23 at 11:52 a.m., Res #16 was observed sitting in a geri-chair in the dining room positioned to look out the window. The resident was observed to be clean, dressed, and not in obvious distress. The resident was unable to be interviewed. The resident's hard chart and EHR were reviewed and no documentation of the follow up from the hospital visit on 04/12/23 were located. On 07/31/23 at 4:15 p.m., MDS coordinator #1 provided documentation from the physician they had ordered extended neuro checks on the resident and if anything changed the physician would consider further imaging. The MDS coordinator stated they thought the physician may not have followed up as the resident had a history of a previous traumatic brain injury and their condition. 4. Res #80 was admitted on [DATE] and had diagnoses which included dementia with behavioral disturbance. A base line care plan, dated 04/03/23, documented the resident was exit seeking and to redirect to room when wandering into others rooms. An admission assessment was not available. A nurse note, dated 04/03/23 at 9:35 p.m., documented Res #80 was wandering the facility and was exit seeking. The note documented the resident was entering other resident rooms and turning the lights on and had to be redirected but continued to pace the halls. A nurse note, dated 04/04/23 at 10:30 p.m., documented the resident was wandering up and down the halls and entering other resident rooms. The note documented the resident refused to go to their room and continued entering other resident rooms and going through their belongings. The note documented the resident stated, This is my house and they are in my rooms and I can go where I want. The note documented the staff continued to try to redirect the resident and the resident slapped a CNA's arm when the CNA placed their hand over a light switch to prevent Res #80 from turning on the light. The note documented the staff continued to walk with the resident as they paced the halls to attempt to redirect them when they tried to enter other resident room. The note documented Res #80 was paying no attention to redirection attempts. A nurse note, dated 04/04/23 at 11:04 p.m., documented the nurse was called to the end of the hall as Res #80 was attempting to climb out of the window. The note documented documented Res #80 punched the nurse in the jaw on the lower side of their face when they attempted to close the window and told the resident they could get cut by glass if they tried to break through the glass. The note documented the resident then returned to their room and sat in a recliner. The note documented the administrator was notified of the incident. A nurse note, dated 04/05/23 at 2:36 p.m., documented Res #80 was attempting to open a window in the front office and climb out and attempted to swing at the BOM. A nurse note, dated 04/05/23 at 3:11 p.m., documented the resident was in another resident's room and was swinging at staff for trying to close the window. The note documented Res #80 also was swinging at therapy personal for assisting the nursing staff. The note documented the physician was contacted and the resident was sent to ER for evaluation and treatment at a geri-psych unit. A nurse note, dated 04/05/23 at 10:16 p.m., documented the resident was brought back to the facility as the hospital did not think the resident needed a psychiatric evaluation and had contacted APS and obtained a police escort to return the resident to the facility. The note documented the family were notified that no acts of aggression towards staff or other residents would be tolerated and the resident would be referred out for geri-psych the next day for an appropriate evaluation. A nurse note, dated 04/07/23 at 5:50 a.m., documented Res #80 was constantly having to be redirected to not go in other resident rooms. A nurse note, dated 04/08/23 at 7:12 p.m., documented a woman called the facility to notify the nursing staff Res #80 was crawling out of the bedroom window. The note documented the nursing staff found the resident walking towards the highway. The note documented the staff returned the resident to the facility and placed the resident on 15 minute visual checks. A nurse note, dated 04/09/23 at 3:58 p.m., documented the resident had been placed in isolation due to a positive COVID-19 test and was non-compliant. A nurse note, dated 04/11/23 at 9:18 p.m., documented the resident was positive for COVID-19 and was up and ambulating around the facility. A nurse note, dated 04/12/23 at 2:30 a.m., documented 15 minute visual check completed at 12:45 a.m. The note documented around 12:50 a.m., Res #80 was in the room of Res #10, grabbing and clawing at the resident. The note documented Res #80 yelled at Res #10 to get out of bed and out of their house. The note documented Res #10 went to the bathroom to clean blood off of their arms and Res #80 went to Res #16's room and pulled defenseless resident on to the floor. The note documented a CNA responded by protecting Res #16 from Res #80s screaming and angry rage. The note documented 911 was notified and police, fire, and ambulance responded quickly. The note documented Res #80 responded by swinging at staff and throwing mouthwash on the officers. The note documented the EMTs were reluctant to transport Res #80. The note documented the ambulance left with Res #80 to a geri-psych unit at a hospital. A Discharge summary, dated [DATE], documented the residents provisional diagnosis was dementia with behavioral disturbance and the final diagnosis was dementia with severe behavioral disturbance. On 07/31/23 at 9:18 a.m., the DON stated they had Res #80 on 15 minute checks and a CNA had just walked by. The DON stated they heard yelling and the resident was attacking two other residents as well as the staff members. The DON called EMS, the police, and contacted the physician right after EMS was called to get the resident to a place they could receive help. On 07/31/23 at 5:00 p.m., the administrator, RN #1, and the MDS coordinator, were in the administrator's office and were asked if they had any knowledge Res #80 could possibly become aggressive. The MDS coordinator stated the facility had been actively seeking placement in an geri-psych facility since the resident returned from the hospital after striking a staff member on 04/05/23 and the resident was placed on every 15 minute checks due to the elopement attempts. RN #1 confirmed every 15 minute checks had not worked to prevent exit seeking behavior and the resident should have been placed on one-on-one supervision. The MDS coordinator stated it would be hard to say if one on one supervision until placement in a geri-psych facility would have prevented the resident from attempting to hurt others but it might have made it much less likely.