**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 31 sampled residents, that the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident sustained a fracture while receiving Passive Range of Motion (PROM) therapy services and did not receive an x-ray to diagnose the injury or treatment for two additional days after the injury occurred. This was cited at a harm. Resident identifier 25. Findings included: Resident 25 was admitted to the facility on [DATE] with diagnoses which consisted of quadriplegia Cervical (C)1-C 4 complete, Pressure Ulcer (PU) right heel stage 3, PU left elbow stage 2, PU right elbow stage 2, gastrostomy, hypotension, polyneuropathy, muscle spasms, insomnia, gastro-esophageal reflux disease, functional dyspepsia, pain, tracheostomy, chronic respiratory failure, adjustment disorder with mixed anxiety and depressed mood. On 11/29/21 at 2:36 PM, an interview was conducted with resident 25. Resident 25 stated that his shoulder was fractured during range of motion (ROM) exercises that was provided by Restorative Nurse Aide (RNA) 1. Resident 25 stated that this incident occurred sometime last year. Resident 25 stated that RNA 1 was stretching him and his arms were tight and she pushed too hard. Residents 25 stated that it caused him pain, and he knew it was broken because it crunched immediately at the time of the incident. Resident 25 stated that RNA 1 was telling everyone that it needed to be x-ray, and she thought that she had broken something. Resident 25 stated that they continued to stretched him the next day and the shoulder crunched again. Resident 25 stated that at that point he had to request to have an x-ray done on the shoulder. Resident 25 stated that they made an appointment with orthopedic physician, and the treatment that was ordered was an abdominal binder to straighten and secure the arm. Resident 25 stated that the shoulder took a long time to heal because staff would continued to reinjure the arm. Resident 25 stated that during showers the staff would remove the binder and then not secure his arm. Resident 25 stated that because he was paralyzed his arm was dead weight and would fall during the showers off the shower chair. Resident 25 stated that he had increased pain from the fracture and had requested an increase in his pain medication. Resident 25 stated that he had always been on oxycodone 10 milligrams and Tylenol for back pain, but after the incident he requested an increase in the pain medication. Resident 25 stated that he was receiving the medication every 6 hours and he asked for it to be given every 4 hours. Resident 25 stated that he was told that he needed to go see a pain specialist. Resident 25 stated that he had pain in the right side of his back due to a titanium bar. Resident 25 stated that the oxycodone provided pain relief for approximately 2 hours. Resident 25 stated that he usually had pain at a score of 7/10 on a scale of 1 to 10, and the pain medication dropped it to about a 6/10. Resident 25 stated that it took 2 weeks before they increased his pain medication. Resident 25 stated that he believed that the arm was fractured a second time during repositioning, but that the staff made excuses that it just was taking a long time to heal. Resident 25 stated that the injury took 7-8 months to heal, but believed that the delayed healing was partially due to the staff reinjuring the arm and not securing it properly during cares. Resident 25's medical records were reviewed. Review of resident 25's progress notes revealed the following entries: a. On 9/5/2020 at 5:35 PM, RESTORATIVE CARE:30 min. (minutes) of prom (passive range of motion) to bue (bilateral upper extremities) and ble (bilateral lower extremities) completed i heard a loud pop sound in pt. (patients) left shoulder, I notify charge nurse immediately. The note was authored by RNA 1. b. On 9/6/2020 at 1:05 PM, PAIN:c/o (complained of) continuous pain, last prn (as needed) oxy (oxycodone) given @ 1300 (1:00 PM), will continue to assess. c. On 9/6/2020 at 5:06 PM, RESTORATIVE CARE:30 min. of prom to bue and ble completed. The note was authored by RNA 1. d. On 9/7/2020 at 11:00 AM, PAIN:(moderate pain) shoulder/neck e. On 9/7/2020 at 11:09 AM, MUSC (muscle)/SKELETAL COND (condition):experiencing pain in shoulder weakness f. On 9/7/2020 at 11:39 AM, The following was texted to MD: Restorative aide was doing ROM exercises on him yesterday and [resident 25] said he heard a popping sound and some pain. He states that it feels like his shoulder/scapula feel sprained. Then today another Restorative aide went in and did his ROM. She states when she moved his arm she could hear like a grinding sound and his arm moved more freely than it usually does. [Resident 25] told her to be careful with his arm after she was done. The aide states his shoulder is not usually that easy to move. MD RESPONSE: X-ray for that shoulder/upper arm please. g. On 9/7/2020 at 1:55 PM, RESTORATIVE CARE:30 minutes of PROM to BLE (bilateral lower extremities) and BUE (bilateral upper extremities) completed. h. On 9/7/2020 at 6:26 PM, INJURY: Right Humerus fracture POSSIBLE CAUSE: Pt has osteopenia INTERVENTIONS New devices: abdominal binder wrapped around arm to keep close to body. STAFF INVOLVED:CNA (Certified Nursing Assistant) WITNESSES: staff i. On 9/8/2020 at 2:27 PM, MUSC/SKELETAL COND: experiencing pain contractures weakness numbness j. On 9/8/2020 at 3:41 PM, TT (tiger texted) [Physicians name omitted] regarding patient wanted more pain medication stating that he feels increased pain in the Right side of neck due to the fractured right shoulder. MD (medical doctor) did not respond. Patient re-assessed stating pain has decreased with regular prn (as needed) analgesic but would still like more medication. MD TT stating he did not want to increase patients pain medication due to complications with over sedation in the past. k. On 9/9/2020 5:57 PM, Late Entry: On 9/5/20 [RNA 1] came to me with a concern about something that happened while doing restorative therapy with [resident 25]. She reported that while doing ROM exercises, she heard a 'loud cracking noise' that sounded like something had broken or was 'not normal'. I proceeded to assess [resident 25] for s/s (signs and symptoms) of a broken bone. Upon my assessment, I did not see any discoloration, swelling, or warmth of his right arm. [Resident 25] did not report any pain but he did report to have heard the loud noise. Upon my assessment, I determined that we should continue to monitor for signs and symptoms of a break and I asked [resident 25] to notify his nurse of any changes to his pain level. I also asked his nurse to continue to monitor for changes. l. On 9/10/2020 at 6:56 PM, patient refused to turn, stated 'I have pain everywhere. [Physician's name omitted] will be getting a call from my lawyer. They have to give me more pain meds (medications). One more is not going to hurt anything.' Patient expressed frustration that MD would not increase oxycodone higher than 40mg milligrams per 24h (hour) period at his request. This nurse reminded patient that MD decreased oxycodone in June and has Rx (prescription) other drugs to help with spasms and neuropathic pain. m. On 9/14/2020 at 5:44 PM, Late Entry: 9/7/20 Xray results of humerus and shoulder show an acute appearing fracture of the right humeral neck with mild displacement. MD notified and ordered his right arm to immobilized and MD will work on Ortho appt. (appointment) Will continue to monitor pt. n. On 9/14/2020 at 5:52 PM, Pt stated he would like the nurse to chart saying, 'I lost 4 pounds in a week, I am not eating because the pain is bad in the right neck and shoulder. If I eat, then the pain medication wont work'. Nurse communicated his concerns with the charge nurse. WCTM (will continue to monitor) o. On 9/14/2020 at 6:03 PM, The following was texted to MD: [Resident 25]. He is having increase in pain on his neck and clavicle. He would like an xray of his neck and one more oxycodone in a 24 hour period. He is currently getting 40 mg in a 24 hour period. He has been doing quite well with this but since his arm is broken the pain is worse in his neck. MD RESPONSE: Ok to both. Review of resident 25's incident report documented the date of the incident on 9/5/2020, made aware on 9/7/2020, and was documented by the Assistant Director of Nursing (ADON) 1. Pt states restorative aide was doing ROM. When performing ROM on right arm pt heard a popping sound in shoulder. After his shoulder felt 'stiff'. Today RA (restorative aide) was doing ROM, before pt made anyone aware still having issues with shoulder, and RA states could hear 'grinding' at shoulder and shoulder moved more than usual. The assessment of the resident documented that the neck, chest, arm, shoulder, and scapula were evaluated. There is no edema, bruising, abrasions and/or any abnormalities appreciated. Assessment is unremarkable. The report documented that the resident was not seen by the physician. The physician was notified on 9/7/2020 at 11:00 AM and ordered to Immobilize shoulder. Bed rest for now. MD will contact ortho surgeon to discuss possible tx. (treatment) (prior ordered x-ray) Review of resident 25's physician orders at the time of the incident (September 2020) revealed the following medications: a. Oxycodone 5 mg Tablet (2 tablet / 10 mg) enteral tube four times a day as needed (PRN). Can be given every 4 hours. DO NOT EXCEED 40MG IN 24HR PERIOD. The order was initiated on 7/22/2020 and discontinued on 9/14/2020. b. Oxycodone 5 mg Tablet (2 tablet / 10 mg) enteral tube five times a day as needed. Can be given every 4 hours. DO NOT EXCEED 50 MG IN 24HR PERIOD. The order was initiated on 9/14/2020 and discontinued on 12/7/2020. c. Tylenol 325 mg Tablet (2 tablet / 650 mg) by mouth every 6 hours as needed. Not to exceed 3000 mg/24 hrs. The order was initiated on 4/12/2020 and discontinued on 1/16/2021. d. NURSING ORDER: Ab (abdominal) binder to immobilize right arm check every 2 hours for skin breakdown, edema, bruising, and any other abnormalities. The order was initiated on 9/07/2020 and discontinued on 10/4/2020. e. NURSING ORDER: LOG ROLL patient when turning to protect right arm. The order was initiated on 9/07/2020 and discontinued on 12/09/2020. Review of resident 25's Restorative Program orders provided by the Physical Therapy Department revealed the following: a. On 9/9/2020 GENTLE P.R.O.M. (passive range of motion) in prolonged stretch to bilateral lower extremity(s) daily 7a-7p b. On 11/1/2021 GENTLE P.R.O.M. in prolonged stretch to BILATERAL upper extremities. Pt. has ostopenia (sic), be mindful of gentle stretching and not pushing past capabilities. daily 7a-7p Review of resident 25's Restorative Program orders provided by the Director of Nursing (DON) revealed the following: a. On 1/17/2020 Restorative to perform UE (upper extremity) PROM in all ranges in prolonged strength (i.e. > (greater than) 20-30 seconds) 5x/week Monday Tuesday Wednesday Thursday Friday 7a (AM)-7p (PM) start on: 01/31/2020 The order was discontinued on 4/23/2020. b. On 4/23/2020 P.R.O.M. in prolonged stretch to bilateral upper extremity (s) daily 7a-7p The order was discontinued on 9/9/2020. c. On 9/9/2020 GENTLE P.R.O.M in prolonged stretch to right upper extremity daily 7a-7p The order was discontinued on 9/10/2020. d. On 9/9/2020 GENTLE P.R.O.M. in prolonged stretch to LEFT upper extremity daily 7a-7p The order was discontinued on 11/1/2021. e. On 11/1/2021 GENTLE P.R.O.M. in prolonged stretch to bilateral upper extremities. Pt. has ostopenia (sic), be mindful of gentle stretching and not pushing past capabilities. daily 7a-7p Review of resident 25's x-ray of the right shoulder on 9/7/2020 revealed there was an acute fracture of the right humeral neck with mild displacement. There was osteopenia. Review of resident 25's x-ray of the cervical spine on 9/14/2020 revealed evidence of a posterior cervical fusion from c2-c6 with mild straightening of cervical lordosis. No compression deformities or subluxation. Mild osteopenia. Review of resident 25's the September 2020 Medication Administration Record (MAR) revealed that the Oxycodone 10 mg was administered 52 times from 9/1/2020 to 9/13/2020 for pain scores, when documented, that ranged from 3 to 9 out of 10 (on a scale of 1 to 10 with 10 being the highest pain possible) before the medication administration. The post administration pain scores were documented as pain reduced with the exception of one administration on 9/11/2020 at 10:39 AM as pain unchanged with a score of 8/10. The documented actions were to continue to observe and encourage rest and reposition. There were 5 administrations of the Oxycodone from 9/6/2020 to 9/14/2020 without a documented pain assessment either prior to administration or after administration for follow-up. On 9/14/2020 the Oxycodone order was changed to 10 mg 5 times a day as needed. On 7/20/2020 resident 25's Quarterly Minimum Data Set (MDS) Assessment documented under Section G for Functional Status that resident 25 was a total dependence with a 2 person physical assist for bed mobility, transfers, and toilet use. Resident 25 was documented as a total dependence with a 1 person physical assist for eating, dressing, and personal hygiene. Resident 25 had documented functional limitations in ROM in both upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) with impairments on both sides (G0400 A&B). On 10/17/2020 resident 25's Quarterly MDS Assessment documented under Section G for Functional Status that resident 25 was a total dependence with a 2 person physical assist for bed mobility, dressing, and toilet use. Resident 25 was documented as a total dependence with a 1 person physical assist for eating and personal hygiene. Review of resident 25's care plan revealed the following: a. On 1/24/2020 a focus area of Comfort, Alteration: in pain, MANIFESTED BY: Communication of pain was initiated. The goals identified were episodes of pain will decrease within 1 hour of intervention, signs and symptoms (s/s) of pain and discomfort will be relieved within 1 hour of intervention, and expressed feelings of comfort or of pain relief. Interventions included nurses administer pain medication as ordered, document pain level, notify MD as needed, monitor/record: medication effectiveness, medication side effects, note characteristics of pain, and note characteristics of respiratory status. Nurse Aide interventions included position for comfort, provide quiet dark environment, offer cool washcloth, and report pain to the nurse. b. On 1/24/2020 a focus area of Impaired physical mobility, RELATED TO: Quadriplegia, Decrease in muscle strength, Weakness/fatigue, Decreased endurance, Decreased ROM, Increased muscle tone. Muscle Spasms, Decreased Mobility, and Neuromuscular impaired MANIFESTED BY: Unsteadiness was initiated. The goals identified were maintain mobility, no s/s of complications, activity participation, no falls or injury, no contractures, safety maintained, and propels self in wheelchair. Interventions included Nurse Aide identify factors that increase resident's potential for injury i.e.: obstacles, unmet needs, etc. Eliminate factors that may increase resident's potential for injury. Reposition minimum every 2 hours, AND/OR PER ACUITY, Utilize pillows for positioning, Report refusals, Check skin during care, Call light in reach, and Use adaptive wheelchair. c. On 11/1/2021 Restorative - Gentle Daily PROM to bilateral upper and bilateral lower extremities for contracture management and joint mobility. On 1/22/2020 resident 25's History and Physical completed by the physician upon admission documented under physical examination for neurologic: consistent with C4 tetraplegia with some diminished light touch sensation. C5 absent below. Slight shoulder shrug. No significant increased tone noted. The assessment and plan documented that the resident had no functional upper extremity motor. Resident 25 had significant neuropathic pain, was on multiple medications, and also felt his spasticity interfered with his pain. Review of RNA 1's competency skills checklist completed on 4/30/2020 documented that RNA 1 had verbalized and demonstrated proper technique for upper extremity range of motion and lower extremity range of motion. The performance criteria was signed by an unknown evaluator and RNA 1. It should be noted that RNA 1 had been performing RNA services for only 5 months prior to the incident with resident 25. On 12/02/21 at 11:17 AM, an interview was conducted with Physical Therapist (PT) 1. PT 1 stated that at times they would create a plan for the RNA services if it was other than basic PROM. PT 1 stated that if it was just basic PROM exercises they would not necessarily put together a RNA program because that would be something that the CNAs would have had training on already. PT 1 stated that they did not put together a plan for resident 25 prior to 9/9/2020. PT 1 stated that all RNA services go through the DON and were coordinated with her. PT 1 stated that the RNA order was provided to the DON to give to the RNAs. PT 1 stated that he did not provide any training to the RNAs for resident 25's program because it was basic PROM exercises. The RNA orders provided for resident 25 were initiated on 9/9/2020 and stated GENTLE P.R.O.M. in prolonged stretch to bilateral lower extremity(s) daily 7a-7p. PT 1 stated that the orders changed on 11/1/2021 to GENTLE P.R.O.M. in prolonged stretch to BILATERAL upper extremities. Pt. has osteopenia, be mindful of gentle stretching and not pushing past capabilities. daily 7a-7p. PT 1 stated that resident 25 did not have an order for an RNA program prior to 9/9/2020. PT 1 stated that the only change to the orders was that the first order just included lower extremities and the second order included the bilateral upper extremities. PT 1 stated that, in general, if we do an order for a patient we would have both upper and lower extremities. PT 1 stated that I don't think that they do things that are not in the order. I think that they would come and ask for clarification before they would add something extra. On 12/02/21 at 12:00 PM, an interview was conducted with RNA 2 and RNA 3. RNA 2 stated that she had worked at the facility for 6 years and had been an RNA for approximately 3 years. RNA 3 stated that she had worked at the facility for 5 years and had been an RNA for approximately 3 years also. RNA 2 stated that the training for the RNA program was through the physical therapy department with a packet that had to be completed. The packet contained information on motions, movements, resistance, and ambulating. RNA 2 stated that the PT would pass them off on the packet. RNA 2 stated that they would go over each new resident's care plan with new orders. RNA 3 stated that each resident would have orders for PT, OT (occupational therapy), and ST (speech therapy), and directions for what that resident's program was. RNA 3 stated that the PT would accompany them for first time with a resident and they could go ask them questions if anything should change and they would reassess. RNA 3 stated that the PT would let them know what the resident's baseline was. RNA 2 stated for PROM they performed exercises with adduction, abduction, repetitive motion, holding, and stretching out. RNA 2 stated that they work all of the extremities including the neck unless otherwise specified. Just whatever is in their order. RNA 2 stated they would not do any PROM exercises that were not specified in an order. RNA 2 and RNA 3 both stated that there were no residents on RNA services that do not have an order. RNA 2 stated that while providing PROM she would support the resident's dead weight for that extremity and feel for resistance and not push past the resistance. RNA 2 stated that she would look for any signs and symptoms of distress or pain and not push past that. RNA 2 stated for the residents that were quadriplegics some could feel and some could talk to us. RNA 3 stated that they would also look for indicators of distress with an elevated blood pressure as some of the residents were continuously monitored. RNA 3 stated that the long term residents on the 2nd and 3rd floor did not have their blood pressures continuously monitored. RNA 3 stated that other indicators of distress with quadriplegics were that they would have muscle spasms a lot if they were in pain or more tense. RNA 3 stated that they would check the resident's pulse oximeter for a elevated heart rate and oxygen saturation for any signs of distress. RNA 3 stated they also watched the resident's facial expression for any tension or anything out of the norm. RNA 3 stated that if we see any abnormal behavior we notify the nurse, notify the PT, and notify their supervisor the DON. RNA 2 stated that most of the time they just notify the nurse and the resident would get PRN pain medication, and they would come back later. RNA 2 stated if it was an ongoing issue or something more severe then they would take it to their supervisor or PT for evaluation before going back to provide services. If we find something abnormal we notify the nurse, then notify the supervisor and she will send out a email to everyone to notify them. RNA 2 stated that she would also call the next shift to notify them that there was a resident change in condition and to alert them to check their email. RNA 2 stated that they were supposed to check their email daily anyway's. RNA 2 stated that all of their documentation was completed under restorative nursing. On 12/02/21 at 3:08 PM, a telephone interview was conducted with RNA 1. RNA 1 stated that she had worked at the facility for 9 years, and had been an RNA for the last 2 years. RNA 1 stated that her training was in ROM therapy and was provided by other RNAs and the Physical Therapy department. RNA 1 stated that the training consisted of ROM exercises, ambulation with a resident, communication, and sign language with a book. RNA 1 stated that with ROM we hold the arms and legs. We bend the shoulders and legs, bend the arms, bend the knees, hips, all the way to the feet and ankles. RNA 1 stated that each resident had specific treatment and different orders. RNA 1 stated that the first time she provided a treatment to the resident another RNA would accompany her and if it was a new resident the Physical Therapist (PT) would show them how to do the exercises. RNA 1 stated she did not provide RNA services to residents without an order. RNA 1 stated that during ROM exercises she supported the arm with the left hand and made sure that she could see the resident's face to see if they were crying, or making faces in distress. RNA 1 stated that for residents who could talk they would tell her when to stop. If they moan we stop. RNA 1 stated that she looked for facial expressions or noises to see when she needed to stop. RNA 1 stated that she always did slow ROM exercises. RNA 1 stated that sometimes she can feel when the bone can bend this much, you can feel when you need to stop. RNA 1 stated that they [residents] don't have the flexibility to open their arms, we don't open it more than they can, we know their limit. RNA 1 stated that she was doing ROM with resident 25. RNA 1 stated that if you did not do what resident 25 wanted he called you names. RNA 1 stated that she was working on resident 25's right arm and was grabbing his arm and was pushing his shoulder up and down, and when she pushed it up it cracked. RNA 1 stated that she heard a cracking sound. RNA 1 stated that resident 25 was telling her during the PROM exercise that it could go more. RNA 1 stated that from her experience with working with resident 25 that she could feel that she was meeting resistance, but that she pushed past the resistance due to resident 25's prompting. RNA 1 stated that when she did this the arm cracked and she said see [resident 25's name] it cracked. RNA 1 stated that resident 25 then laughed at her. RNA 1 stated that resident 25's ROM order stated to do gentle ROM to both the upper and lower extremities. RNA 1 stated that after the injury occurred she went and told Charge Nurse (CN) 1 right away that they needed an x-ray to know if it was broken, because she heard it crack and pop. RNA 1 stated that was all she said and that they would take care of it. RNA 1 stated that she did not report the incident to anyone other than CN 1. RNA 1 stated that she believed that CN 1 then called her supervisor, the DON. RNA 1 stated that she filled out an incident report that day. It should be noted that an incident report completed by RNA 1 was not provided by the facility. RNA 1 stated that she went back the following day and provided resident 25 ROM exercises. RNA 1 initially stated that she did not provide ROM exercises in resident 25's right upper extremity on 9/6/2020. When asked about the documentation on 9/06/2020 at 5:06 PM, RESTORATIVE CARE:30 min. of prom to bue and ble completed. RNA 1 confirmed that it was documented by her. RNA 1 then stated that she only performed PROM exercises on resident 25 right extremity up to his elbow and did not go to the shoulder. RNA 1 stated that she did not document correctly, that the charting did not indicate this, and that she should have provided more detail. On 12/02/21 at 4:00 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that if it was reported to her that a resident had sustained a suspected injury during ROM exercises she would assess the resident then report it to the charge nurse. RN 3 stated that she would follow-up the physician to make sure that there were no new orders and continue to monitor the resident for any change in condition. RN 3 stated that she would also follow up with the RNA to make sure that this was not a trend and that there were no other residents with injuries. RN 3 stated that she would definitely notify the doctor or make sure that the charge nurse notified the doctor. On 12/02/21 at 4:04 PM, an interview was conducted with RN 4. RN 4 stated that if an RNA reported a suspected injury during ROM exercises she would assess the resident, and report it to the charge nurse. RN 4 stated that the charge nurse would alert the physician and the charge nurse would initiate the incident report. RN 4 stated she would make sure that the physician was notified and assess the resident. RN 4 stated that she would conduct a CMS check (circulation, motor, and sensory check). RN 4 stated that if the resident was a quadriplegic she would rely on the resident's baseline status. RN 4 further elaborated and said that she would rely on what the resident/witness had said had happened and not necessarily what they feel with regards to sensory as the sensory could be diminished with a quadriplegic. RN 4 stated that she would definitely do an x-ray on the affected area that was injured. RN 4 stated that it would be appropriate to notify the physician right away, and that they could text the physician. RN 4 stated that if the change in condition was more serious or urgent the charge nurse would call the physician directly. On 12/02/21 at 4:13 PM, an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) 1. The DON stated that the RNA training was done with training packets and assessed by the PT to pass off all the skills. After they have their pass off they can go by themselves to provide RNA services, but most go 2 by 2. The DON stated that the RNA should be providing services based on the order provided from PT. Each resident should have specific orders from PT. They may alter it from active to passive ROM, but not the other way around without an evaluation. The DON stated that if they were to see that the resident was getting stronger they would get an order to have PT evaluate the resident again. The DON stated that they do not provide any ROM services to residents without orders. The DON stated that if the patient was alert and oriented the patient was the best advocate, and I would assume that the RNA would not push it and push past the point to do harm. I would still expect it to be within safe parameters. The DON confirmed that there was an element of clinical judgement with RNA 1 and experience with resident 25, and RNA 1 should have known what the capabilities were of resident 25. The DON stated that RNA 1 reported the incident with resident 25 to CN 1 and he assessed the patient. The DON stated that CN 1 determined that there was no pain and redness and that they were going to monitor resident 25. The DON stated that they spoke to CN 1 and educated him that they needed to be informed immediately because they would have taken a different route than he took that day. The DON stated that they would have obtained an x-ray that day. The DON stated that this was not their protocol at the facility. The DON stated that resident 25 was not complaining of pain the day of the incident, but was not aware that CN 1 had documented that resident 25 had reported to have heard the loud noise. The DON stated that it was fair to say that resident 25 had some sensory deficit with his diagnosis of quadriplegia. The DON stated that CN 1 did not notify anyone of the incident, and that they became aware of the incident on Monday when another RNA reported it again. The DON stated that she was not aware that CN 1 had entered a late entry note and did not know that he had documented that the RNA had reported, a 'loud cracking noise' that sounded like something had broken or was 'not normal' . The DON stated that CN 1 should have notified the physician first and then notified the her. On 12/06/21 at 10:35 AM, a follow-up interview was conducted with PT 1. PT 1 stated that PROM was moving a joint through full ROM and was passive. PT 1 stated that the patient could not contribute and the expectation was that the caregiver would go joint to join and move through the motion. PT 1 stated that each PROM program was patient specific and wi[TRUNCATED]