**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it has been determined that the facility failed to address signs of behaviors that the resident was exhibiting such as disrobing self, wandering, pacing the unit and declining care/medications since his/her admission to the facility, as documented in the medical record. Additionally, the facility failed to ensure that each resident receives and is provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, for 1 of 1 resident reviewed, Resident ID #2. Findings are as follows: On [DATE] the Rhode Island Department of Health received a facility reported incident that states in part Just prior to the change in shift, the on-coming RN [Registered Nurse] went to check on the residents in room [room number redacted] 2/2 [secondary to] door being closed. Abuser [Resident ID #2] was found to be blocking entry into the room however upon gaining access, the RN noted the room looked like bed linens were spread around the room and general disorder. Victim [Resident ID #1] was in the bed but was noted to be motionless and pale. On closer assessment, the RN noted what looked like pillow stuffing inside the mouth of victim and that [s/he] had expired . Record review revealed Resident ID #2 was admitted to the facility on [DATE], after an acute hospital stay following an episode of confusion and paranoid behavior while at home. Resident ID #2 was admitted to the facility with medical diagnoses including, but not limited to: encephalopathy (a disease in which the brain alters the brain function or structure), delirium (disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings) anxiety disorder, urinary tract infection and stroke. Record review of the Hospital Neurology Consult document dated [DATE], authored by the neurologist, states in part, .[Resident] who is admitted to medicine for agitation and altered mentation with neurologic exam notable for inattention .it is likely that [resident] is delirious and confused with poor cognitive reserve .At this time, favor delirium and [s/he] may need time to improve given poor cognition reserve. -No further neurologic work up indicated at this time- Would utilize nonpharmacologic interventions to minimize risk of delirium . Additional review of the hospital discharge paperwork indicated the resident needed a follow up appointment with his/her Community Psychiatric Provider. Record review of the resident's follow up appointments revealed the facility had scheduled an appointment for Resident ID #2 for [DATE]. Record review of Resident ID #2's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 3 out of 15, indicating severe cognitive impairment. Further review of the MDS revealed the resident was coded as having an acute change in mental status from his/her baseline indicating s/he has fluctuating inattention. Additionally, s/he is coded as feeling down, depressed, or hopeless, having trouble concentrating, having trouble falling asleep and feeling tired or having little energy. Further review of the MDS indicates the resident has behaviors not directed towards others and rejection of care. Record review of Resident ID #2's psycho-social well-being care plan dated [DATE] revealed [Resident] is diagnosed with encephalopathy and delirium and has significant decline in cognitive and functional levels since hospitalization. [Resident] is at risk for decline in psycho-social well-being and mood fluctuations due to personal and significant life events (recent illness and decline in functioning, transition to new environment and PTSD [post-traumatic stress like symptoms] -[resident] is a veteran and did serve in the war). Interventions which state in part, SS [social services] to provide [resident] with support around acclimation to new environment and staff will provide consistency with routines. SS to provide 1:1 visit for support and encourage [resident] to participate in activities and Diversional tasks that are self-soothing and meaningful to [him/her], assess for any triggers or changes in moods/behaviors and report to clinical team .create a calm and nurturing environment to promote a sense of safety and belonging, decrease stimuli in environment as able, psych services as needed for further support . Record review of Resident ID #2's behavioral care plan dated [DATE] revealed the [Resident] is diagnosed with encephalopathy and delirium and has had a significant decline in cognitive and functional levels since his/her hospitalization. [Resident] has been noted to exhibit behaviors of disrobing self, wandering, and pacing the unit and declining care/medications, particularly during times of increased restlessness, confusion, and disorientation. [S/he] requires frequent redirection, cueing and supervision. Interventions which state in part, Staff to address [Resident] by [his/her] name and utilize simple and direct instructions and questions and care. Staff to provide gentle redirection, cueing and explanations of assistance as needed during periods of increased behaviors. Encourage engagement in diversional activities to distract and decrease periods of restlessness and anxiety. Assess for needs and comfort levels and limit distractions and stimuli as able. Psych services as needed for further supports and symptom and med [medication] management. Re-approach at later times during periods of resistance to care . Record review of Resident ID #2 nursing progress notes revealed the resident exhibited behaviors on the following dates and times: -[DATE] at 2:21 AM s/he was found in another resident's room wrapped in a bed sheet. -[DATE] at 5:23 AM s/he was found standing over roommate, brief removed, donning roommate's shoes. The roommate woke startled. Urine noted on floor. -[DATE] at 5:22 AM .Resident awake at start of shift. Verbal and communicative at times. Amenable to bedrest at 12:00 AM. Slept well for approx 3 hours. Awake at 3 AM, attempting to manipulate roommate's wheelchair and belongings .Requires repetitive step by step cueing. Resident remained awake for approx 2 hours. Required near constant redirection and supervision during that time . -[DATE] at 9:40 AM .Resident OOB [out of bed] and ambulating ad lib this AM, resistive to contact guard assist, physically pulling away from caregiver touch. Stand by assist maintained. Resident attempted exit out of 2 doors in front sitting room, 'looking for my [spouse]'. Resident reassured [his/her spouse] knows where [s/he] is and will be in soon to spend time with [him/her]. Demonstrating STM [short term memory] loss as resident would ambulate again to exits within 3-5 minutes. 1:1 supervision for approx 45 minutes. Sitting at times with peers, briefly. Entered peers rooms, redirected with good effect. Flat affect, answers simple questions, denied discomfort, refused snacks/beverages. In common area at present for supervision. -[DATE] at 10:00 AM 1:1 supervision was removed as the resident appeared calm and relaxed. Shortly after the alarm sounded and the resident exited the building. Immediate staff response. The resident was initially resistive to returning but ultimately cooperative. 1:1 reinstated and remained in place . -[DATE] at 1:51 AM the resident was seeking exit door. -[DATE] at 4:39 AM .Awake at approx 330 am. Resident found ambulating in room, disrobed. Assisted to bathroom provided. Resident found disrobed ambulating in room attempting to urinate short time after toileting .Refusing bed rest at present .however d/t [due to] STM deficit . -[DATE] at 4:47 AM .disrobed with urine on floor. Required frequent redirection. Fidgeting with chux [disposable bed linens for incontinent care] and bed linens .sleeping at approx 2am. -[DATE] at 12:57 PM Resident unaware of [his/her] surroundings. Requesting to have the sheriff called, 'the propane tanks are going to blow up'. Redirection not comprehended. This writer assisted resident to the BR [bathroom] to urinate per resident's request. Upon arrival to the BR resident indicated that the tub was the toilet .Resident then proceeded to take top off of bowl as [s/he] wanted to fix it. 'There is too much water in there, can you hand me my tools' . -[DATE] at 6:24 AM Resident attempted to elope X 2. Redirected by staff. -[DATE] at 6:08 AM Resident voided on roommate's floor mat. Resident found naked and assisted back to bed . -[DATE] at 8:22 AM Resident alert, not present mentally. Roams the facility with no clear intentions. Arbitrarily takes [his/her] pants down to defecate .Needs cueing to eat, redirected several times to sit and eat .Unable to give this resident a shower r/t [related to] mentation .insistent [s/he] needs to see a doctor .repeating [his/her] medical number . -[DATE] at 4:45 AM Resident awake at start of shift. Donning clothing and shoes, saying 'Good morning' to staff and peers. Unable to reorient resident to the time of day. Resident ambulating throughout the unit .Attempted to exit through North wing fire exit .Removed clothing independently X 3 this shift. Urinary void on floor .Resident fell asleep at approx 130am, slept for approx. 3 hours total this shift. Awake at present. Close monitoring for safety. -[DATE] at 9:59 AM Resident with increased anxiousness .refused pills .some confusion still noted .some redirection needed . -[DATE] at 5:25 AM Resident awake at start of shift. Confusion with some delusions noted. Insisting that [s/he] needed to leave to go 'fix' something. Unable to redirect or reorient. Reminded resident to need of stay at facility, resident unable to comprehend .Slept well in bed from approx 1230am until approx 430am. Upon waking, resident removed clothing and incontinent products, urinated on floor. Staff cleaned and redressed, this occurred x 2 more times despite toileting and redirection .resident perseverating on 'gathering up' things. Attempts to redirect and reorient were ineffective . -[DATE] at 6:20 AM .disrobing and urinating on the floor occasionally throughout the shift . -[DATE] at 12:03 AM Resident awake, pulling off clothes wanting to urinate in the corner and breakroom .Acting defensive when asked to please go to bed. Refused to put on pants. Allowing resident to roam as unable to redirect. Close eye placed on resident, tendency to urinate on whom and whatever [s/he] wishes to . -[DATE] at 11:13 AM .Resident eloped. Redirected back into the facility . -[DATE] at 12:38 AM Resident awake shortly after beginning of shift. Difficult to redirect. Took clothes and brief off several times. Needing 1:1 observation. RN providing 1:1 .Continue to observe resident for elopement risk. -[DATE] at 4:01 AM At time of this note resident still awake, ambulating unit. Declines to sit down. Resident states [s/he] will go to bed when everyone else does. This writer explained to resident that all of [his/her] peers are currently. Asked resident again if [s/he] would want to go to bed. Resident agreed. RN walked resident to bed, resident easily distracted by any object in [his/her] room. After about 10 minutes RN able to get resident into bed. -[DATE] at 4:57 AM Resident out of bed within 10 minutes of this writer putting [him/her] to bed .Very manic at this time. Roaming the lower level looking for exits to get out of. Unable to redirect resident .RN needing to provide 1:1 observation for this resident during rounding. Resident constantly taking off clothes . -[DATE] at 11:44 PM Resident having an emotional break. This RN was called to lower level. Found this resident with a metal clock/decoration banking [sic] with another hard object 'FREE THE PEOPLE'. This writer tried to defuse the situation, able to get resident to walk back to [his/her] room. Resident immediately went to roommate banging metal object .FREE THE PEOPLE .Remained in allway [sic] chanting . -[DATE] at 12:14 AM When EMS [emergency medical services] arrived resident still using a hanger beating on a clock. EMT staff and police officer unable to redirect resident to get onto stretcher . -[DATE] 1:46 PM Resident arrived from local hospital at 1:30 PM .instructions from hospital as follows, patient brought to emergency department for episode of delirium .recommendations for next line providers at SNF [skilled nursing facility] please consider ordering as needed's for agitation for this patient such as Seroquel [antipsychotic medication used to treat mental/mood conditions] . -[DATE] 9:34 PM Resident again urinated on the floor. Redirected to his/her own bed. Resident refused shower and medications. -[DATE] at 5:46 AM Resident sleeping at the start of shift. Resident awake at approximately 12am .removing clothing and bed linens . -[DATE] at 3:20 AM Resident awake for duration of this shift. Agitation, delusions and pacing noted at 12am. Resident voicing concerns of 'ships' 'water' 'helping the people' and 'what would God want you to do?' This writer provided 1:1 supports, frequent reorientation to time and place were briefly effective .Residents behaviors de-escalated after approx. 45 minutes of 1:1 support. Resident took one very brief nap. Awake at present, constant ambulation throughout the hallway, attempting to open office doors. Removing and reorganizing bedding. Resident adamantly refusing bedrest despite voicing being tired and desire to sleep. Stating [resident] wanted Blankets to put on the floor in various locations to sleep 'because I want to'. Insistent despite this writer attempting to redirect resident to bed. Resident becoming politely aggravated with this writers 1:1 supervision .Resident continued asking for blankets, attempting to make 'bed' on wooden gossip bench in common area. Resident agreeable to going in room, but adamantly refusing bedrest because 'I don't want to'. despite continuing to voice being tired. Resident began removing coat hangers from closet and placed them on floor. Attempting to push this writer out of the way when attempting to pick up hangers to avoid tripping. Resident easily redirected. Also pushing this writer when attempting to pick up blankets off of floor that resident laid out. Resident currently in room, making and reorganizing bed linens ambulating to and from room . -[DATE] at 4:35 AM .Donning and doffing clothes repeatedly. Urine noted on the floor near roommates side of room. Resident refusing staff to allow staff to enter the room . -[DATE] at 9:48 PM .staff attempted to change [resident's] brief and [resident] became 'somewhat combative' . Record review of the facility's provider's admission note revealed a note dated [DATE] which states in part, .delirium-felt multifactorial, including UTI [urinary tract infection] CT [cat scan] brain ok, had some neurocog [neurocognitive] decline prior, check MS [mental status], to be evaluated @ [provider] Seen by neurology @ [hospital]. Need have psych see [resident] here . Additional record review failed to reveal evidence that Resident ID #2 was seen and evaluated by their consultant psychiatric services as indicated by the provider on [DATE]. Record review of the hospital After Visit Summary dated [DATE] states in part, Patient was brought to the emergency department for episode of delirium, was back to baseline .Altered Mental Status work-up was negative. Next line providers at SNF Please consider ordering as needed's for agitation for this patient such as Seroquel. Record review failed to reveal evidence of a subsequent revision to Resident ID #2's behavioral or psychosocial care plan or any changes were made to the resident's medication regimen were made following the episode on [DATE] when the resident was evaluate at an acute care facility. Additionally, record review failed to reveal evidence that Resident ID #2 was seen and evaluated by psychiatric services after [DATE]. During a surveyor interview on [DATE] at 11:18 AM with Registered Nurse, Saff B, she revealed she was the nurse caring for Resident ID #2 on the evening of [DATE], during which the resident was observed with a hanger banging on a clock shouting Free the People. She further indicated that at the time of the episode she called to have the resident transported to an acute care hospital for an evaluation, gave the paperwork to the transport attendants when they arrived and then called the receiving hospital with a verbal report. Additionally, she revealed when she called report to the receiving hospital, she reported to the nurse that the resident was banging on a clock with a hanger, unable to be redirected, that s/he was having a mental break and needed a psych evaluation. During a surveyor telephone interview on [DATE] at 12:53 PM with the facility's provider that was overseeing the resident's care at the facility, he revealed that he was aware that the resident was transferred to an acute care facility for an evaluation following an acute episode on [DATE]. Additionally, the provider acknowledged that the acute care facility made recommendations to consider ordering PRN (as needed) medications and he further revealed that he wanted psychiatric services to evaluate the resident prior to adding a PRN medication to address his/her agitation. During a surveyor interview on [DATE] at 1:05 PM with Registered Nurse (RN), Staff E, she revealed that RN, Staff F had contacted the facility's psychiatric services via email on [DATE] after the resident returned to the facility. Review of the email sent to the consultant psychiatric Advanced Practice Registered Nurse (APRN) by Staff F, dated [DATE] at 3:19 PM, revealed a request was made to the APRN to have the resident seen soon, due to an acute episode of a question of delirium and symptoms almost PTSD like. Further revealing that after the previous night's episode, the resident was sent to the emergency room and that s/he had returned at baseline. Additionally, the email revealed that the resident's provider at the facility had requested a psychiatric consult. During a surveyor interview with Staff F, on [DATE] at 9:21 AM, she revealed the facility provider had ordered for the psychiatric evaluation following the resident's hospital evaluation on [DATE]. Additionally, she revealed that she sent the email to the consultant psychiatric APRN on [DATE] and would have followed up with her on Friday if Resident ID #2 had not been seen yet. During a surveyor interview on [DATE] at 12:05 PM with the consultant psychiatric APRN, she revealed that she had not received the email from the facility and could not explain why. She further revealed that if she had received the email, she would have responded to them that day. Additionally, she indicated that if it was urgent, the facility could call her, and she or a colleague would have come to see the resident that day. Lastly, the APRN revealed delirium can wax and wane and can be prolonged and would want to treat any underlying problem and then prescribe an antipsychotic medication. Record review revealed that Resident ID #1 was admitted to the facility in September of 2021 with diagnoses including, but not limited to Alzheimer's disease, dementia, and Parkinson's disease and s/he was admitted to Hospice services in July of 2022. Additional record review for Resident ID #1 revealed a quarterly MDS dated [DATE] which indicated s/he was dependent on staff for all aspects of care and that his/her cognitive status, mood and behavior was unable to be assessed due to (his/her) severe cognitive impairment. Record review of Resident ID #1's care plan developed on [DATE] states in part, I am at the end stages of life. Please address my psychosocial needs through contact support to help complete the last days of my life with dignity and grace .provide me with one-to-one visits and offer me redirection and TLC (tender loving care) when I become agitated or anxious .Further review of the care plan for ADL (Activities of Daily Living) Deficit .will maintain a sense of dignity by being clean .safe . Additional record review of Resident ID #2's progress notes revealed a progress note dated [DATE] at 12:32 AM, authored by Registered Nurse, Staff A that states in part, Upon arrival to shift this writer noted an incident involving resident [ID #2] and [his/her] roommate [Resident ID #1]. 911 and nursing supervisor contacted. Resident [ID #2] removed from facility by [NAME] EMS at 0027am. [NAME] PD [police department] and AG [Attorney General] in house at present. During a surveyor interview on [DATE] at 10:04 AM with Staff A, she indicated that on [DATE] she entered the facility to start her shift at approximately 10:00 PM. Upon entering the unit, she initially spoke with the second shift nurse, Licensed Practical Nurse, Staff C. Staff C indicated that earlier that shift, Resident ID #2 was combative during care and had required two staff members for assistance with ADLs. Staff A then revealed that after hearing this report, she went to the room of Resident ID #1 and 2 to check on Resident ID #2. When she got to the room she noticed the door was closed, which was not typical. She was able to peer into the room and was noticed by Resident ID #2, who was standing just inside the room in a t-shirt and brief. As she canvassed the room, she noticed that there were blankets, a hoyer pad and chux pads on Resident ID #2's bed. She asked him/her what was going on, the resident stated to her that she couldn't come in the room. She then looked over to Resident ID #1 who was lying in bed and noticed pillow stuffing on (his/her) chest, as she attempted to walk into the room, Resident ID #2 closed the door on her stating, You can't come in here, bye. Staff A approached Staff C to inform her that Resident ID #2 was up to something, and Staff A immediately went back to the room. As she tried to open the door, she was met with resistance by Resident ID #2, but she was able to enter the room by pushing the door open. Once in the room, she observed that Resident ID #1's legs were pale and mottled (blotchy, red purplish marbling of the skin) and she observed what she estimated to be two large handfuls of pillow stuffing on Resident ID #1's chest and face. As she approached Resident ID #1, she observed pillow stuffing in his/her mouth. As she proceeded to remove approximately 2 handfuls of the stuffing from Resident ID #1's mouth; Staff A yelled for staff to assist her stating that [Resident ID #2] killed [Resident ID #1]. Staff responded and escorted Resident ID #2 out of the room. Staff A further revealed that Resident ID #2 stated to her, [s/he] tried to kill me first, [s/he] tried to kill me for 10 years. Staff A indicated that the Police and EMS responded, and EMS pronounced [Resident ID #1] deceased . During a subsequent interview on [DATE] at 2:15 PM with Resident ID #2's provider at the facility, he indicated that he had ordered the psychiatric evaluation on [DATE] more as a formality and did not order the consult to be done stat as it was not urgent. He further revealed that he would have expected the evaluation to be completed in the next week or 2. Additionally, he acknowledged he had ordered an additional psychiatric evaluation following an acute episode on [DATE], after the resident returned from a hospital evaluation. The provider further revealed, considering Resident ID #2's most recent hospital evaluation completed on [DATE], was negative, he would expect that psychiatric services see the resident within a week of the order to further evaluate him/her before starting the resident on any antipsychotic medication. In conclusion, the provider revealed, there was no indication from the resident's behaviors exhibited, that this incident could have been predicted. During a surveyor interview with the Director of Nursing Services on [DATE] at approximately 2:50 PM, she revealed that Resident ID #2 had a follow up appointment with psychiatric services scheduled on [DATE] and that the facility psychiatric consultant was emailed on [DATE] to see the resident. Additionally, she was unable to provide evidence that Resident ID #2 was seen by psychiatric services as ordered to assist in maintaining his/her highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Refer to related citations F600 and F689