**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #2) out of three residents reviewed for abuse, in that: The facility failed to prevent a physical altercation between Resident #1 and Resident #2 that led to Resident #2 sustaining a head injury, subdural hematoma (brain bleed), and subsequent death. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/04/23 at 12:57 PM. While the IJ was removed on 10/05/23 at 11:40 AM, the facility remained at a level of actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk pain, injury, hospitalization, and death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including altered mental status, unsteadiness on feet, generalized muscle weakness, other abnormalities of gait and mobility, and unspecified dementia without behavioral, psychotic, or mood disturbances. Review of Resident #1's quarterly MDS assessment, dated 08/17/23, reflected a BIMS of 3, indicating a severe cognitive impairment. Section E (Behavior) reflected he had not exhibited any physical or verbal behavioral symptoms directed towards others. Review of Resident #1's quarterly care plan, revised 08/22/23, reflected he continued with seeking out female residents who likewise seek him out usually for handholding with an intervention of monitoring/documenting/reporting to the MD any changes in cognitive function. Review of Resident #1's Behavioral Health Diagnostic Assessment, dated 09/15/22, reflected he displayed no agitation or irritability symptoms, or hostility and he had moderate disorientation (altered mental state with loss of sense of time, identity, direction, and place). Review of Resident #1's monthly psychiatric progress notes, from 09/18/2022 - 09/04/23, reflected no documentation of any verbal or physical outbursts or aggression episodes. Review of Resident #1's NP notes, dated 09/19/23, reflected the following: [Resident #1] is pleasant and cooperative with assessment. He is generally a poor historian and has a documented slow decline of cognition, ambulatory. He is followed by psych for mild depression. No behaviors noted. Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness, difficulty in walking, abnormalities of gait and mobility, unsteadiness on feet, and unspecified dementia without behavioral, psychotic, or mood disturbances. Review of Resident #2's quarterly MDS assessment, dated 07/20/23, reflected a BIMS of 7, indicating a severe cognitive impairment. Section E (Behavior) reflected he had not exhibited any physical or verbal behavioral symptoms directed towards others. Section G (Functional Status) reflected he required supervision for ambulating. Section J (Health Conditions) reflected he had experienced falls since admission, one resulting in a major injury (bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma). Review of Resident #2's quarterly care plan, revised 07/20/23, reflected he had actual falls on 11/30/20, 12/15/20, 03/10/21, 02/18/22, 03/10/22, 10/21/22, and 07/14/23 with an intervention of notifying the charge nurse if increased weakness, attempting to transfer self, and potential hazards in the room. Review of Resident #2's nursing note in his EMR, dated 09/30/23 at 9:00 AM and documented by RN A, reflected the following: [Resident #2] was transferred to a hospital on [DATE] at 9:00 AM related to an altercation that occurred between [Resident #2] and his roommate, [Resident #1]. Per [MA B], she heard yelling between [Resident #1] and [Resident #2] and saw [Resident #1] shove [Resident #2]. [Resident #2] lost his balance and fell backwards into the floor hitting his head. EMS activated and he was transferred to (hospital). Review of Resident #2's incident report, dated 09/30/23 at 9:18 AM and documented by RN A, reflected the following: [RN A] was notified by [MA C] that [Resident #2] had been pushed and was on the floor. Upon assessment, [Resident #2] was confused and unable to answer questions for several minutes. After approx. 5 minutes, [Resident #2] was able to answer questions and denied pain but was not able to get up from floor due to weakness and decreased coordination. [MA B] stated that [Resident #2] and his roommate [Resident #1] were arguing and that [Resident #2] was shoved by [Resident #1] and fell to the floor. Resident Description: [Resident #2] unable to give description. Review of Resident #2's nursing note in his EMR, dated 09/30/23 at 6:16 PM and documented by RN A, reflected the following: Called (hospital) to check on status of [Resident #2]. Talked to the nurse and was told [Resident #2] is intubated after receiving a Cranel ectopy (a surgery done to remove a part of your skull in order to relieve pressure of the brain). But doing good. Review of Resident #2's hospital records, dated 09/30/23, reflected the following: HPI: . Per EMS report by [Resident #2]'s facility he was pushed by his roommate and ended up falling striking his head . Discussion of imaging findings: [NAME] called to discuss [Resident #2]'s head imaging noting extensive intracranial bleeds including a large 17mm subdural hematoma, with blood extending along the posterior right falx (the largest of the four partitions of the dura mater) and right knee from ventilatory him. There is some parenchymal hemorrhage (a bleed that occurs within the brain parenchyma, the functional tissue in the brain) in the right frontal operculum (may refer to the frontal, temporal, or parietal operculum, which together cover the insula as the opercula of insula), minor subarachnoid blood, parenchymal hemorrhage in the left frontotemporal region. Discussion with other healthcare providers: Consulted with trauma surgery given [Resident #2]'s head bleed secondary to a traumatic fall. On reevaluation prior to trauma come to see him noted to have an abrupt change in mentation noting that he had a rightward gaze, was not following commands anymore and was not moving his left arm or leg against gravity. Trauma surgery updated on change in [Resident #2]'s mentation, neurosurgery consulted at this time and updated as well . Repeat imaging showing increase in the subdural hematoma and decision was made to take [Resident #2] emergently to the OR for intracranial hemorrhage evacuation. Hospital Course: [Resident #2] admitted for a fall requiring emergency craniectomy; [Resident #2] had postoperative complication of seizures. On post-op day 1, [Resident #2]'s family decided to proceed with withdrawal of care. [Resident #2] was made comfortable and comfort care orders measures were instituted. Review of the facility's description of the incident between Resident #1 and Resident #2, dated 09/30/23 and documented by the ADM, reflected the following: Verbal exchange between the two residents (Resident #1 and #2) began at breakfast service; [Resident #1 and Resident #2] were separated and [Resident #1] went to his room and [Resident #2] stayed in the dining area. After meal service, [Resident #2] returned to the room and the argument ensued again. Staff responded immediately to find [Resident #2] on the ground. No witnesses to have observed who initiated the incident. [Resident #2] hit the back of his head on the floor and was sent to (hospital) via EMS for further evaluation and treatment. Review of a witness statement regarding the incident between Resident #1 and Resident #2, dated 09/30/23 and documented by MA B, reflected the following: I, [MA B], was sitting at the nurses' station at about 8 AM on Saturday 30 of Sept. 2023 with [MA C] when we heard two male residents having an altercation. The voices sounded like [Resident #1] and [Resident #2]. I sat up in a hurry to head to their room and separate them and when I turned the corner I saw [Resident #2] falling straight back to what would look like a trust fall. Upon seeing this I ran down the hall to him and [Resident #1] was standing in front of [Resident #2] at the doorway and [Resident #2]'s walker was in between them. I asked [Resident #1] why he was fighting with [Resident #2] and told him he is like a brother. [Resident #1] replied back and said, I pushed him I'm sorry and he turned around and went to his bed. A moment later [MA C] ran up with [RN A] who was the charge nurse at the time. [LVN D] the other nurse on the floor called EMS . Review of a witness statement regarding the incident between Resident #1 and Resident #2, dated 10/02/23 and documented by MA C, reflected the following: Incident started in the dining room during breakfast when [Resident #1] was arguing with [Resident #2]. [Resident #1] was yelling across the dining room to [Resident #2] about something. [Resident #2] then told [Resident #1] to shut up, to which [Resident #1] said something about breaking his jaw. [Resident #1] was redirected to his room since he was done eating and to help the arguing from escalating while [Resident #2] went and sat at a table to eat his breakfast. I (MA C) went to sit behind the nurses' desk with [MA B]. After a little bit we started to hear two people arguing down hall 3. [MA B] and I got up because it sounded like it as getting pretty heated between the two. And before we could make it around the corner we heard [Resident #1] continuing to yell and then a couple of words were said from [Resident #2] and then heard a loud thud. [Resident #2] was on the floor flat on his back. During a telephone interview on 10/03/23 at 10:35 AM, RN A stated on in the morning of 09/30/23, she was sitting in the DON's office when MA C came and told her Resident #2 was on the floor. She stated she went down there to assess him (Resident #2), and he was dazed, confused, and unable to answer questions which was very unlike him. She stated she noticed there was blood on the floor under his head and requested LVN D call 911. She stated after the EMT's took Resident #2 out, she asked Resident #1 what happened. She stated Resident #1 told her, He (Resident #2) pushed me first, so I (Resident #1) pushed him back and he fell. She stated she had never seen either resident exhibit physically aggressive behaviors to each other or anyone else. She stated she heard they (Resident #1 and #2) had a verbal altercation in the dining room prior to the incident but could not remember who she had heard that from. During an interview on 10/03/23 at 11:07 AM, MA B stated she was at the nurses' station on the morning of 09/30/23 when she heard Resident #1 and #2 arguing. She stated she immediately got up and headed toward their room, as she turned the corner at the entrance of hall 3, she saw Resident #2 falling backwards. She stated she heard Resident #1 state that he pushed Resident #2. She stated she had never witnessed Resident #1 being verbally or physically aggressive to staff or residents. She stated she did not witness a verbal altercation earlier that morning between the two residents, but MA C told her there had been one. During a telephone interview on 10/03/23 at 12:07 PM, MA C stated she witnessed Resident #1 and #2 arguing in the dining room in the morning of 09/30/23. She stated Resident #1 was on the opposite side of the dining room yelling something at Resident #2 who replied, shut up and Resident #2 stated something along the lines of, I'll break your jaw. She stated Resident #1 was redirected to his room and she did not see Resident #2 walk by when he went back to the room. She stated if she had, she would have paid more attention to ensure both residents were no longer upset with each other. She stated she heard Resident #1 shouting and then Resident #2 saying a few words and then heard a thud. She stated Resident #2 was on the ground on his back, was not responding, and he was in a state of shock with his eyes wide open. She stated she was not sure if Resident #1 pushed Resident #2 or if he just fell backwards. During a telephone interview on 10/03/23 at 3:06 PM, Resident #1's PNP stated she had been assessing him monthly since he was admitted to the facility for inappropriate sexual behaviors. She stated he had never exhibited any kind of physical or aggressive behaviors per her assessments and staff updates. She stated Resident #1 was a lover not a fighter, was always in a jovial mood, and did not believe he would have remembered the verbal altercation 30 minutes after it happened. She stated he could not remember something that happened five minutes prior, let alone 30 minutes prior. She stated she did not believe he (Resident #1) could have done something such as pushing Resident #2 down to the floor. During an interview on 10/03/23 at 3:24 PM, CNA E stated she had never witnessed Resident #1 being aggressive or exhibiting and physical behaviors. She stated she could not imagine him being physically aggressive to anyone. She stated he was very pleasantly forgetful and did not believe he would have remembered the verbal altercation 30-45 minutes later when Resident #2 returned to the room after he finished his breakfast. During an interview on 10/03/23 at 3:30 PM, the AD stated Resident #1 had never been physically or verbally aggressive to anyone. She stated he spoke loudly and spoke his mind but was extremely forgetful. She stated she did not believe he would have even remembered the verbal altercation that ensued 30 minutes before Resident #2 was found on the floor. She stated there was a family member of another resident in the dining room at the time of the verbal altercation. She stated the family member told her Resident #1 was loudly asking Resident #2 how he was, and Resident #2 replied with, None of your damn business, shut up! She stated the family member did not hear a reply from Resident #2, but a nurse requested he go back to his room. She stated the family member told her Resident #2 willingly left the dining room and had not seemed upset. During an interview on 10/04/23 at 9:26 AM, RA F stated he had never seen Resident #1 be verbally or physically aggressive to anyone. He stated he was friendly to everyone, especially the female residents. He stated if he witnessed two residents having a verbal altercation he would separate them, keep an eye on them, and would not leave them in an area alone together until he ensured the issue had been defused. He stated he had been trained to redirect and keep residents separated after any kind of altercation. During an interview on 10/04/23 at 9:33 AM, LA G stated she had never witnessed Resident #1 being verbally or physically aggressive to anyone. She stated if she had witnessed two residents in a verbal altercation she would immediately redirect and separate them. She stated if it were her, after the verbal incident on 09/30/23, she probably would not have thought to accompany Resident #2 back to his room because he was so laid back and Resident #1 would probably not have even remembered the incident by that time. She stated Residents #1 and #2 had always gotten along without any issues. During an interview on 10/04/23 at 9:38 AM, LVN H stated Resident #1 had never been verbally or physically aggressive to anyone nor had she ever seen Residents #1 and #2 not getting along. She stated if she witnessed a verbal aggression incident between two residents, she would separate them and ensure they were both safe and would make sure the hostility had defused before they were in the same vicinity again. She stated when it came to the incident on 09/30/23 regarding Residents #1 and #2, she did not believe Resident #1 would have even remembered the verbal altercation that had ensued 30 minutes prior. During an observation and interview on 10/04/23 beginning at 9:46 AM, Resident #1 was in his room with a caregiver providing 1:1 supervision. Resident #1 was very kind and jovial (cheerful and friendly) but did not answer all questions appropriately. This Surveyor left his room and waited in the hall for four minutes before returning to Resident #1's room. Upon reentering the room, Resident #1 acted as if he had never met or seen this Surveyor before. During an interview on 10/04/23 at 10:42 AM, the ADM stated her expectations after a verbal altercation between two residents, was for the staff to intervene and separate and redirect the residents. She stated she believed the staff handled the incident on 09/30/23 between Residents #1 and #2 appropriately. She stated Resident #1 was immediately sent to his room while Resident #2 finished his breakfast. She stated after 30 minutes she did not believe Resident #1 could have remembered the incident in the dining room. She stated the residents had been roommates for a long time without ever any issues and Resident #1 had no history of physical behaviors or aggression. She stated after someone informed her Resident #1 had mentioned he pushed Resident #2, he was immediately put on 1:1 supervision for 72 hours and until his PNP assessed him and deemed 1:1 supervision unnecessary. She stated no one witnessed how Resident #2 ended up on the floor, so there was no way of knowing whether he was pushed or fell backwards on his own. She stated she had made a report to the police who had come out to the facility and determined that they would not be pursuing the investigation due to Resident #1's advanced dementia and the fact that the incident had not been witnessed. Review of Resident #1's psychiatry progress note, dated 10/02/23 and documented by Resident #1's PNP, reflected the following: Per staff, [Resident #1] was over-heard having a verbal confrontation with his roommate and staff went to them. [Resident #2] was found on the floor, possibly pushed by [Resident #1] . No recall of altercation with roommate. We're good friends - I love all my people. Could not recall roommate's name, I think it's Spanish. Smiles, pleasant. Direct questions about incident - no memory. Assessment: Dementia advanced. No memory of incident with his roommate. Apparently immediately after incident [Resident #1] told nurse, He pushed me first. [Resident #1] has No history of aggression and is pleasant. He tends to be affectionate and friendly to all. No need for 1:1 supervision. Review of the facility's Abuse and Neglect Policy, revised 03/29/18, reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined in this subpart . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents . 1. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. . The above policy will apply to potential resident-to-resident abuse. Provider Letter 19-17 will be reviewed to determine if resident-to-resident abuse occurred. Review of HHSC's Provider Letter 19-17, dated 07/10/19, reflected the following: Allegations or incidents of resident-to-resident behavior may or may not meet the definition of abuse depending on whether a resident acted willfully. The CFR states, Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The ADM, DON, and RCN were notified on 10/04/23 at 12:57 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 10/05/23 at 9:26 AM: Plan of Removal Problem: Abuse allegation All residents have the potential to be affected by any resident-to-resident aggression be it verbal/physical. Interventions: Alleged perpetrator interviewed and placed in 1:1 observation 10/4/23at 1539 and continues currently. AP will remain on 1:1 until PCP/Psych Serv review and evaluates safety to remove 1:1. Abuse prevention in-service for all facility staff initiated and completed by Administrator/Director of Nurses/Compliance Nurse on 10/4/2023at 1539 . Administrator and DON received all in-services provided by the Regional Compliance Nurse on 10/4/23 at 1539 Staff were in-serviced on Abuse and Neglect policy, AN Reporting, wWho to report Abuse and Neglect to and Resident to Resident aggression Verbal/Physical. Staff expectation wasis to report all Abuse/Neglect known or suspected to the abuse coordinator immediately to include all Resident to Resident Aggressive Behaviors either verbal or physical. Staff are to separate the involved residents and place aggressor/aggressors on 1:1 until the Interdisciplinary team/MD (Primary Care Physician/Psychiatric Services) clear the resident/residents for no longer being a threat to each other / other residents. Immediate psychiatric services on call for identified residents in need 10/4/2023 1539 Medical Director contacted 10/4/23 1539. Discharge placement ordered for alleged perpetrator on 10/4/2023 1539. AP wasis being discharged to a sister facility r/t the small and close Millieu (a person's social environment)at the current facility. Negative comments could affect the AP's Quality of Life. The discharge was discussed with the AP's family and arrangements made tofor tour of the sister facility. The order was obtained from the PCP. Staff working with alleged perpetrator have been interviewed by DON to determine any possible/continuing aggressive behavior and to determine any possible pattern. Resident safe surveys have been completed by social services 10/5/23. The following in-services were initiated on 10/4/23 1539: Any staff member not present or in-serviced on 10/4/2023 1539, will not be allowed to assume their duties until in-serviced. All Staff Abuse/Neglect Abuse/Neglect Reporting Who to Report Abuse/Neglect to Resident to Resident Aggression Verbal/Physical All staff to include PRN and Agency staff if used will not be allowed to work until in-services are received. In-servicing will continue for all current staff until 100% compliance was is obtained and continue for all new hires as they occur. Monitoring Administrator/DON to Investigate and submit findings resident to resident verbal/physical aggression to Area Director of Operations/Regional Compliance Nurse and Risk Management for review. The task will follow the regulatory compliance of reporting immediately but no later than 2hours if there is an injury and or 24hours if there is no injury and investigation will be submitted within 5days. Administrator/DON will submit documentation of investigation with Resident and Staff interviews. Documentation of investigation with resident and staff interviews will be submitted to ADO, Regional Compliance Nurse and Health and Human Services Center as part of the 5 day5-day self reportself-report investigation. Initiate weekly follow up interviews with 8 staff members per week x 4 weeks to ensure resident to resident verbal/physical protocols are followed. Admin/DON will initiate and facilitate interviews beginning 10/5/23. ADO/Regional Compliance Nurse will monitor weekly x 4 weeks and follow up on monitoring of resident to residentresident-to-resident altercations verbal/physical beginning 10/5/23. ADHOC QAPI will be held on 10/4/23 1539. The QA committee will review findings monthly for no less than 60 days and makes changes as needed. The Surveyor monitored the POR on 10/05/23 as followed: During interviews on 10/05/23 from 10:52 AM - 11:35 AM with the HSKS, one LA, the ADON, two CNAs, two LVNs, one MA, and one RA revealed they all stated they were in-serviced before their shifts on abuse and neglect, types of abuse, and the protocol of handling situations of verbal and physical altercations between residents. All staff members were able to relay different types of abuse such as physical, mental, verbal, sexual, and misappropriation of property. They all stated that their ADM was their Abuse and Neglect Coordinator and all suspicions of abuse or neglect should be reported to her immediately. All staff members stated that if they witnessed a verbal or physical altercation between residents that they would separate them immediately, make sure they were safe, would immediately notify their charge nurse and ADM, would check on them every 15 minutes, and would not let them be in the same area alone until they were sure the hostility had been defused. All stated that if the residents involved in the altercation were roommates, they would not let them return to their room together alone. Review of an Ad Hoc QAPI Meeting Agenda Summary, dated 10/04/23, reflected the MD, RCN, ADM, DON, PNP, DM, BOM, HSKS, and DOR were in attendance. Review of Abuse Interview Questions, dated 10/05/23, reflected all residents were questioned about abuse and their feelings of safety at the facility with no concerns. Review of an in-service entitled Abuse and Neglect, dated 10/04/23 and conducted by the DON, reflected staff were educated different types of abuse and reporting all allegations or concerns of abuse or neglect to the ADM immediately. Review of an in-service entitled Resident to Resident Verbal and Physical Aggression, dated 10/04/23 and conducted by the DON, reflected staff were educated on the protocol for handling situations revolving incidents of verbal and physical aggression between residents. While the IJ was removed on 10/05/23 at 11:40 AM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.