**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, electronic medical record (EMR) review, observation, interview, and policy review, the provider failed to ensure one of one resident (1) was not abused by staff registered nurse (RN) (C), licensed practical nurse (LPN) (D), and certified nurse aide (CNA) (E) during the administration of a medication injection. Findings include: 1. Review of the provider's 11/8/24 SD DOH FRI revealed: *Resident 1 had a recent visit to the tribal Indian health service (IHS) emergency room (ER) on 10/23/24 related to increased aggressive behaviors toward other residents and staff. *The ER physician, tribal judge, facility medical director, and resident 1's guardian had consulted and agreed he was a risk to himself and others and would benefit from inpatient behavioral health care. *An inpatient placement was not available, he was placed on the waiting list and started on two medications for the aggressive behaviors. *On 10/30/24, resident 1 was seen by doctor of nurse practitioner (DNP) O; she ordered an antipsychotic medication injection to begin in one week. After the initial injection it was to be administered once every four weeks. *On 11/5/24 at approximately 2:20 p.m., seemingly in a good mood following a behavioral health visit with LPN D, director of nurses (DON) (B) determined it would be a good time to approach resident 1 about the new injection. She accompanied RN C and LPN D to resident 1's room. -He was awake and resting in bed. -DON B approached him and asked if it would be okay to give him the injection. -He immediately became aggressive, he was refusing and saying no, he was not taking any insulin. -LPN D attempted to explain the medication and provide reassurance it was not insulin but would help him with his mood; again he adamantly refused. -At that point, DON B determined to wait until the next day when DNP O and LPN M would be there as resident 1 had a good rapport with them. They then left his room. *On 11/5/24 at approximately 2:30 p.m. RN C and LPN D had CNA E accompany them and returned to resident 1's room. -He appeared to be sleeping. -While LPN D and CNA E stood by, RN C administered the injection in his right upper arm. -After the injection was administered, resident 1 became upset, stood up from his bed, swinging at the staff, he slipped and fell down on his knees and then to the floor hitting his head on slippers and the floor. -He had no loss of consciousness. -He refused an initial assessment and was assisted up from the floor to his bed by the CNA and LPN. -Neurological checks were initiated and his guardian notified. *On 11/5/24 at approximately 2:40 p.m. the DON learned of the incident of the injection being given and the resident's subsequent fall. -She immediately went to resident 1's room to assess him and asked him what happened. -He replied, They came in here and gave me that damn shot, I didn't want it and it pissed me off so I tried to hit them and ended up on the ground. Now I got this and pointed at his head. -He had a large hematoma over his left eyebrow, the skin was intact; he was able to see three fingers being held up by the DON. *On 11/5/24 at approximately 3:15 p.m. assistant DON (ADON) (N) assessed resident 1. -The hematoma over his left eyebrow measured 5.3 X 7 X 3 centimeters with purple coloration in the center. -He complained of pain at an 8 out on a scale 0 to10 with 10 being the worst. -The hematoma and the back of the right side of his head were tender to touch. -He was drowsy and mumbled his words. -He agreed to be seen in the ER. -The ADON contacted the physician for an order to send him to the ER and updated his guardian. *On 11/6/24, RN C was officially suspended, LPN D's employer was notified she was not to return to the facility pending the outcome of the investigation. Review of resident 1's EMR revealed: *He was admitted on [DATE] following a series of falls. *He had diagnoses that included previous alcohol abuse, high blood pressure, type 2 diabetes with high blood sugars, dementia, agitation, and bipolar disorder. *He was on medications for elevated blood pressure and cholesterol, oral and injected insulin for diabetes, for dementia, agitation, and bipolar disorder. *His Brief Interview for Mental Status (BIMS) assessment score was 11 that indicated he had moderate cognitive impairment. *He had a history of trauma from having been assaulted by a male acquaintance in the past. *His care plan reflected he could be very aggressive with other males and females; easily agitated by loud yelling and those that wander into his room; and his refusal to take medications including insulin as well as refusal to shower and observe personal hygiene. *Care plan approaches included: -Staff to be consistent and firm yet gentle and calm in approach. -Do not argue, leave and reapproach later. -Document refusal and behaviors, report to the charge nurse. -Offer choice in timing for shower. *Physician notifications of medication refusals. *Resident's guardian/son notifications of refusal to take medications, shower and observe personal hygiene, as well as aggressiveness toward other residents and staff. *Between 8/14/24 and 11/5/24, there were 66 entries related to refusal to take medications including insulin, refusal to allow blood sugar checks, refusal to shower or observe personal hygiene, and demonstration of aggressive verbal and physical aggressiveness toward other residents and staff. Random observations on 11/18/24 between 12:30 p.m. and 14:35 p.m. of resident 1 revealed: At 12:30 p.m. he was lying in bed snoring quietly. While he was not shaved, he did not appear unkempt. At 1:10 p.m. he continued in bed, sleeping; did not arouse when his name was spoken. At 2:00 p.m. he was awake in his wheel chair requested assistance back to bed, staff summoned. He was not interested in talking to this surveyor. At 2:35 p.m. he again was sleeping, snoring quietly. Interviews on 11/18/24 between 12:35 p.m. and 2:55 p.m. with staff about resident 1 revealed: *At 12:35 p.m. RN F stated he had had multiple instances of aggressive language and behavior toward other residents and staff. Staff had received re-education about abuse following the the incident where he was given the injection and fell. *At 1:20 p.m. LPN G shared his care plan does have approaches for his aggressiveness and staff do keep track of his behaviors and refusals. Staff received re-education from the administrator and ADON about abuse. *At 1:30 p.m. LPN H stated she had been working on the other hall the day of the reported incident and was aware he had refused the injection that was given while he was sleeping. Staff were re-educated and that education is also in the communication book. *At 1:50 p.m. social services I stated she was aware of the incident and received re-education about abuse. *At 2:05 p.m. restorative aide J stated she was aware of the incident with resident 1 and had received re-education about abuse. *At 2:15 p.m. CNA K stated she was aware of the abuse of resident 1 and had received re-education about abuse. *At 2:45 p.m. CNA L shared following the incident with resident 1 he had received re-education about abuse. Interview and review of the FRI and facility internal investigation on 11/18/24 at 3:00 p.m. with administrator A and DON B revealed: *DON B had been in her office when she stepped out and saw a staff member heading to resident 1's room with an ice pack. She was informed he had fallen on the floor following receiving the injection. She went to his room to investigate the situation. -After doing a preliminary assessment herself, she returned to the office to notify administrator A as she was out of town. -After leaving a message for administrator A, she received a return call around 3:00 p.m. from her. -She didn't begin the complete investigation until after resident 1 was sent out to the ER. -RN C received official notification of suspension. -LPN D's employer was notified she was not to return to the facility. -CNA E was not suspended. He had started at the facility three shifts prior to the date of the incident and when interviewed on three separate occasions he believed he had to follow all the orders given by the RN. He had been told to hold resident 1's arm while he was getting the shot. He received one-to-one re-education and the staff education on abuse. *Administrator A concurred with DON B that she was out of town and received notification of the incident around 3:00 p.m. on 11/5/24. -They had open communication with resident 1's guardian/son, the medical director, the behavioral health employer of LPN D, law enforcement, and the ombudsman. -At the conclusion of their investigation they made the determination to terminate RN C. -They received notification from LPN D's employer on 11/8/24 that they had terminated her from employment. -She and ADON N had provided staff re-education about abuse and their abuse policy on 11/8/24 and that education was also available in the staff communication book. *Both DON B and administrator A stated they did not believe the staff involved in the incident intended harm to resident 1 but they had ignored the decision to wait until the next day to reapproach, and did not follow resident 1's care plan approach interventions or the facility policy. *During the course of the investigation they did not identify any other residents who may have incurred abuse with medication administration. *A Quality Assurance Performance Improvement meeting was planned to occur in early December when the medical director was to be available. Review of the provider's reviewed 11/1/24 Abuse, Neglect, and Exploitation policy revealed in the definitions: Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 11/18/24 after record review revealed the facility had followed their quality assurance process, education was provided to all nursing staff regarding medication administration and abuse, interviews revealed staff understood the education provided regarding those topics, observation of the resident revealed no signs of emotional distress, and review of his record revealed no documented ongoing signs of resident distress related to the reported incident. Based on the above information, non-compliance at F600 was determined on 11/5/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 11/18/24, the non-compliance is considered past noncompliance.