Based on clinical record review and facility policy review, it was determined that the facility failed to prevent resident to resident physical abuse by one resident (Resident 42) to ensure that each resident was free from abuse, resulting in harm (pelvic fractures) for one of 29 sampled residents (Resident 98). This deficiency is cited as past non-compliance. Findings include: Review of the facility policy entitled, Abuse Policy - Prevention and Management, last revised September 8, 2022, revealed the facility prohibited the abuse of residents, must provide a safe environment, and must protect residents from abuse. Resident to resident abuse was defined as the individual's action was deliberate and willful. Willful physical actions in resident to resident altercations included, but were not limited to, hitting, grabbing, slapping, and shoving. Clinical record review revealed that Resident 42 had diagnoses that included Alzheimer's disease (disorder that causes problems with memory, thinking, and behavior), anxiety disorder, depression, dementia with behavioral disturbance, and psychosis (a severe mental disorder in which contact is lost with external reality). Review of nursing documentation and the care plan revealed that the resident had a history of behavioral disturbances, including verbal aggression towards residents and staff and hitting staff. Interventions included to refer to the psychiatrist/psychologist, as needed. Nursing documentation, dated July 20, 2022, noted that Resident 42 was the aggressor in a physical altercation with another resident (Resident 3) and the intervention of 15 minute checks was added to the care plan. Resident 42 had a psychiatric consultation on July 27, 2022, and recommendations included to offer behavioral interventions and psychiatric follow-up in six weeks and as needed. There was a lack of documentation to support that 15 minute checks continued after August 2, 2022, and Resident 42 continued to threaten and display physicial aggression towards other residents as evidenced by nursing documentation; including: attempting to hit or put hands on other residents on August 23 and 25, 2022, waving a fist at other residents on August 28, 2022, attempting to grab other residents (behavioral interventions unsuccessful) on September 10, 2022, pushing other residents out of the way on September 24, 2022, and rolling around in the wheelchair threatening to hit other residents (interventions unsuccessful until resident placed in bed) on September 28, 2022. Nursing documentation on September 30, 2022, at 1:45 p.m., noted that Resident 42 displayed increased behaviors and verbal aggression towards staff and other residents. Further nursing documentation on September 30, 2022, at 7:05 p.m., indicated that the resident was self-propelling the wheelchair in the corridor and Resident 98 was walking in the opposite direction. Resident 42 reached out and shoved Resident 98, causing Resident 98 to fall. Resident 98 was observed with a bleeding head wound and sent to the hospital. There was a lack of documentation to support that additional interventions were implemented to ensure that Resident 98 remained free from abuse from Resident 42. Resident 98 returned to the facility on October 1, 2022. A nurse's note dated October 2, 2022, stated that Resident 98 complained of pain in both legs when moved and that the resident had not been out of bed since returning from the emergency room. An x-ray obtained on October 2, 2022, revealed that Resident 98 sustained acute pelvic fractures with the need for a computerized tomography (CT or CAT) scan (medical imaging technique used to obtain detailed internal images of the body). Documentation by the orthopedic surgeon on October 6, 2022, indicated the CAT scan confirmed that Resident 98 had sustained multiple fractures of the pelvis. There was a lack of evidence that Resident 42's physician and/or psychiatrist were notified of the resident's ongoing aggressive behaviors towards other residents from August 23, 2022, through the incident on September 30, 2022, when Resident 98 was harmed as the result of Resident 42's aggressive behavior. Information available to the Department included the following corrective actions in response to the abuse by Resident 42: A. Following the altercation with Resident 98, Resident 42 was put on one to one supervision on September 30, 2022. B. The physician was notified, laboratory testing was ordered, and psychotropic medications were adjusted for Resident 42 on September 30, 2022. C. Resident 42 was seen by the Family Nurse Practitioner (FNP-C) and psychotropic medications were adjusted on October 3, 2022. D. Resident 42 was transferred to the hospital on October 5, 2022, for dementia with underlying behavioral disturbance. The resident received a psychiatric evaluation with psychotropic medication adjustments. E. The facility implemented 15 minute checks October 6 through November 4, 2022. F. Resident 42 was seen for behavior and medication review by the Certified Registered Nurse Practitioner (CRNP) on October 7, 2022, post hospital visit. G. Resident 42 was evaluated and psychotropic medications were reviewed by the physician on November 2, 2022. H. Resident 42 was seen by the psychiatric CRNP for follow-up evaluation and psychotropic medication management on December 13, 2022, and January 21, 2023. I. Resident 42 had displayed a decrease in behavioral symptoms with no further resident to resident abuse after September 30, 2022. J. During the Full Health Survey, Resident 42 was observed February 12 through February 15, 2023, and there were no observations of behavioral symptoms exhibited by the resident. K. Interviews with the unit nurse and nurse aide on February 15, 2023, at 11:40 a.m., supported that Resident 42's behavioral symptoms had decreased and had not been directed at other residents. L. Interviews with the unit nurse and nurse aide on February 15, 2023, at 11:40 a.m., supported that staff were aware of behavioral interventions to be implemented for Resident 42 and of the need to notify the physician of any changes. This deficiency is cited as past non-compliance. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 201.29(a)(j) Resident rights. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 28 Pa. Code 211.16(a) Social services.