**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, facility policy review, and staff interviews, the facility failed to ensure 1 out of 7 Residents, (R)59, reviewed for abuse out of a total sample of 39 residents, was free from abuse. A resident-to-resident altercation resulted in harm to R59 when he sustained a fractured finger. Findings include: Review of the facility's revised November 2019 policy titled, Abuse, indicated, Each resident has the right to be free from abuse .Residents must not be subjected by anyone, including, but not limited to facility staff, other residents .Abuse is defined as the willful infliction of injury .with resulting in physical harm, pain, or mental anguish. Willful: The individual must have acted deliberately, not that the individual must have intended to inflict injury of harm .Physical abuse includes but is not limited to hitting, slapping, pinching, and kicking . Review of the facility's revised January 2017 Abuse policy titled, Prevention, indicated, It is the policy of the facility to provide residents an environment free from abuse through prevention .The facility will identify residents whose personal histories, aggressive behaviors, and/or communication needs render them at risk for abuse and/or abusing other residents .The facility will monitor residents for changes that could trigger abusive behavior . Review of the facility's revised January 2017 Abuse policy titled, Protection, indicated, It is the policy of the facility to provide residents an environment free from abuse through protection .With resident-to-resident abuse, the residents will immediately be separated. The behaviors and physical condition of the residents will be evaluated with appropriated interventions identified to address the behaviors . Review of the facility's revised September 2017 Abuse policy titled, Investigation, indicated, It is the policy of the facility to thoroughly investigate .any allegations of abuse that include Physical Abuse .Allegation of Abuse: 1. The resident(s) will be evaluated for any physical, emotional, and/or cognitive changes. 2. Identify: if possible, the date of the alleged abuse and immediately begin an investigation. 3. Interview the resident. 4. Interview and obtain written statements from the person(s) reporting the allegation .7. Obtain written statements from individuals identified as possibly having any knowledge of the allegation. At the conclusion of the investigation, the Administrator and Director of Nursing (DON) and designated staff will review all evidence and reach a conclusion if abuse has been substantiated, and any corrective actions to be taken . Review of the facility's revised October 2012 policy titled, Administration Policy and Procedure Directives-Memory Care Unit, indicated, It is the policy of this facility to provide each resident who is diagnosed with dementia, a safe and structured environment in the State Veterans Home that meets their physical, emotional, social .needs throughout the disease's progression. Review of an undated Face Sheet provided by the facility revealed R59 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease, dementia, and Post-Traumatic stress disorder. Review of R59's Minimum Data Set (MDS) provided by the facility with an Assessment Reference Date (ARD) of 06/03/22 indicated a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated R59 had severe cognitive impairment. Review of an undated Face Sheet located in R92's electronic medical record (EMR) under the Profile tab revealed R92 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease, malignant neoplasm of the brain, and dementia. Review of R92's quarterly MDS provided by the facility with an ARD of 04/29/22 indicated a BIMS score of 4 out of 15, which indicated R92 had severe cognitive impairment. Review of an Accident/Incident Reporting Form Bureau of Health Facilities Licensing, 24-report provided by the facility and dated 06/01/22, indicated a resident-to-resident altercation took place between R59 and R92 on 06/01/22. It indicated no witnesses present. The 24-report indicated, On 06/01/22 at approximately 9:00 am, resident [R59] (BIMS-8) approached the nurse and reported he broke my finger. Upon assessment, the left 4th finger appears displaced and bent toward the left 3rd finger with slight redness and blue discoloration beginning to form at the base of the finger. When asked what happened, resident [R59] stated, he [referring to R92] came in my bathroom and attacked me. He hit me in my jaw and bent my finger. A 1cm (centimeter) red area was noted on his right cheek. [Name of R59] then pointed to resident [R92] (BIMS-4) and identified him as the person who hurt him. When [name of R92] was asked what happened, he reported words were exchanged and that he whooped him. Resident [R92] had a 1 cm pink area observed on the bridge of his nose. Both residents were separated, assessed, neuro checks completed and were within normal limits for both residents. An order was given to send R59 to the emergency room for evaluation of his finger. R92 was sent to the hospital for psychiatric evaluation. Review of the 06/01/22 hospital X-ray results provided by the facility for R59, indicated, Findings-There is marked degenerative changes of the first carpometacarpal joint. There is a comminuted slightly displaced fracture at the base of the proximal phalanx of the fourth digit. The X-ray results indicated, Impression: Comminuted slightly displaced fracture at the base of the proximal phalanx of the left fourth digit. Degenerative changes of the left hand. Review of a Psychosocial Visit dated 06/01/22 provided by the facility, indicated, Met with [name of R59] for psychosocial visit .was asked to start at the beginning. He said, It was one of those things. Asked him what happened. He said, I don't know really. He went on to say, He was in the bathroom. My finger got in the way. Asked [name of R59] if he hit the man [referring to R92]. He said, No. Asked him if he was upset. He said, No. I asked if the man hit him. He said, No. Review of a Departmental Note dated 06/01/22 provided by the facility, indicated, Resident [R59] approached this nurse [Licensed Nurse (LN)2] stated, He broke my finger. Resident [59] wearing boxers and a collared shirt and socks. Noted left 4th finger displaced, bend [sic] toward left 3rd finger with slight redness at first (after body audit noted blue discoloration beginning to form at base of finger) .body audit completed. Noted another resident [referring to R92] walking in the same hallway. This resident [R59] pointed at the other resident [R92] and stated, that's him. Other resident [R92] stated, He shouldn't have been running his mouth that way. This nurse [(LN)2] asked the other resident [R92] what happened. The other resident [R92] stated, I was getting comfortable in the bathroom, and he [R59] came in and ask [sic] if I thought I could whoop him. I told him yes and I did. Review of a Nurse Practitioner Note dated 06/02/22 provided by the facility, indicated, [R59] assessed in r/t [related to] altercation with another resident resulting in a fx [fracture] of 4th finger. [R59] was sent to the ER for evaluation of hand .splint was placed and was re-x-rayed in ER which showed: Mild improved alignment of the fourth proximal phalanx fracture. When asked what happened, resident [R59] stated, He got me in the bathroom. I probably hit him and didn't even know it after he hit me in the eye. [R59] denies any c/o [complaints of] pain. Able to move thumb, index, and middle finger of L [left] hand with complaints. Able to move all extremities. No discoloration to face/cheek/eye. Review of a second Accident/Incident Reporting Form Bureau of Health Facilities Licensing document 5-day report, dated 06/06/22 and provided by the facility, indicated a summary of events as was indicated in the 24-hour report and, [name of R59] sent to the emergency room where a finger reduction took place and the Xray revealed mild improvement alignment and a fracture of the fourth proximal phalanx. A finger splint has been put in place. Will be assessed by an Orthopedist on 06/06/22. Review of a Hospital Occupational Therapy Visit-OT Evaluation dated 06/06/22, indicated, This is an .male patient who was in an altercation with another demented resident at the nursing home where he resides resulting in the injury to the ring finger .Type of Splint- prefabricated, custom. Purpose of Splint- Provide protection and safe healing position. Treatment- Tolerated well. Patient was educated in proper wear and care. Further review of the document indicated, The patient is experiencing no tenderness .Comments: Gross swelling about 4th and 5th digit with ecchymosis (bruising) present. Assessment: He was referred to occupational therapy for a custom splint. Review of a hospital Orthopedic Surgery Office Visit dated 06/06/22, indicated, New patient-left ring finger. Pt. [patient] got into an altercation with another resident at the VA [Veterans] last week. Pt [patient] has a splint on today .He went to the ED [emergency department] and had a fractured proximal phalanx of the 4th digit which was displaced and reduced in the ED. He has a splint, but his daughter stated he has been taking it off. He denies pain . Review of a Physician Order dated 07/05/22, provided by the facility, indicated, D/C [discontinue] tx [treatment] to L [left] 4th finger. Res [resident] non-compliant with brace. During an observation and interview on 08/17/22 at 11:04 AM, R59 was observed in his room lying down. During interview regarding the resident-to-resident altercation that took place on 06/01/22 between R59 and R92, R59 stated, All I really recall is a guy was winding up his fist. It's been about 9-10 weeks ago. When asked what happened, R59 stated, I wasn't paying no attention and I put my hand on the shoulder of a guy in front of me. I put my finger on the shoulder of a guy. He said, I'm winding up and it happened a pretty good while ago. I don't remember a lot of stuff. It wasn't that bad of a fight. I went to the hospital, but they didn't do anything. It was a stupid fight. All I did was to karate chop him with my hand and that was the end of that. I think I hit him, but I don't remember where. I can't recall it. At this time R59 could not recall any specifics of the resident-to-resident altercation. During an observation of R92 on 08/17/22 at 2:00 PM, R92 was observed in his room. During this time, R92 was not interviewable and when asked about any incidents could not recall. During an interview on 08/17/22 at 4:00 PM, the Social Services Director (SSD) stated, With [name of R59], he has a history of being territorial. He has a pattern of cursing at other residents if they come in his room. He startles easily. He has PTSD [Post Traumatic Stress Disorder] related to his time in war. Regarding the resident-to-resident altercation that occurred between R59 and R92, the SSD stated, The private room adjacent from [R59] was vacant. There is a bathroom that connects both rooms. From what we could determine, [R92] came in that vacant room and went to the bathroom. [R59] was sitting on the toilet and from we could determine, [R92] said [R59] yelled at him, and [R92] must have grabbed [R59's] hand. [R59] told us that He hit me in the face and broke my finger. During an interview with the Assistant Director of Nursing (ADON) on 08/18/22 at 2:03 PM, the ADON stated she did the 5-day follow up investigation. The ADON stated, They were not roommates at the time of this incident. From what [R59] reported, he approached [LN2] and reported, he broke my finger. [LN2] noticed some deformity to the left finger. [R59] pointed to [R92] who was walking down hallway and said he was the one. It occurred around 9:00 AM, so staff were finishing breakfast, cleaning up trays, starting to give showers, etc. Both families were notified. Prior to this there were no altercations between these two residents. None of their demeanors had changed and neither recalled the details of the incident. Since then, these two residents have had no altercations with one another. They pretty much keep to themselves and have no history of seeking out one another. During an interview on 08/19/22 at 10:18 AM, regarding the resident-to-resident altercation between R59 and R92, the SSD stated, We are going off what R59 reported to staff, we think R92 may have stood up from the toilet and attempted to hit R59 in the face because R59 was pointing his finger at R92 when sitting on the toilet. In an effort to try to block R92 from being hit in the face, grabbed R59's his hand/finger and that is how R59's finger got broken. The SSD stated, Staff heard the commotion and went in the room and [R59] reported to staff. The SSD stated, R59 reported to the nurse, he came into my bathroom, hit me in the jaw and broke my finger. During an interview on 08/19/22 at 6:19 PM with the Administrator and Director of Nursing (DON), the Administrator stated, With [name of R59] he may not have struck out. He was in a private room and is very territorial and thinks that is his bathroom. Per the DON, [name of R59] came up to the nurse and told the nurse what happened, but we couldn't say for sure that [name of 92] broke R59's finger. [name of R59] could have hit his finger on the door, sink, wall. We can't say for sure that [name of R92] intentionally intended to break a person's finger or [name of R59] finger. We can't say that it was willful, sought out abuse by R92. We just can't. We only have to report what was being reported to us by [name of R59] which we did. With it being unwitnessed, we cannot say [name of R92] broke his finger. We are not substantiating abuse in any way. We are simply saying there was some sort of resident-to-resident altercation that occurred, but not abuse.