**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review it was determined that the facility failed to protect one of 39 residents in the survey sample from resident-to-resident abuse, Resident #44. On 6/24/22, Resident #37 hit Resident #44, which required an emergency room visit where they were diagnosed with a closed fracture of the distal end of the left ulna (1), closed head injury, abrasion of the nose and a closed fracture of the nasal bone, resulting in harm. The findings include: Resident #44's (R44) most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 5/1/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is cognitively intact for making daily decisions. Section E documented no behaviors. Section G documented R44 requiring supervision with transfers, walking in the room and corridors and locomotion on and off the unit. Section G documented R44 not having any impairment in the functional range of motion to the upper and lower extremities and being not steady but able to stabilize without staff assistance when walking. On 6/27/2022 at 5:14 p.m., an interview was conducted with R44 in their room. R44 was observed lying in bed and was observed to have a splint wrapped with an elastic bandage on the left forearm. When asked about the splint on the left forearm R44 stated that they were hit by another resident with a cane in the solarium at the end of the hallway the previous Friday. R44 stated that they had a fracture in the arm and a fractured nose from the incident. R44 stated that they had gone to the emergency room and they had taken x-rays, applied the splint and advised them to follow up with an orthopedic physician to see if they needed surgery or not. When asked about the resident who hit them, R44 indicated that Resident #37 (R37) had approached them in the solarium and started hitting them with a cane over nothing and they were crazy. R44 stated that the staff were keeping R37 in their room and were watching them all the time after the incident. The progress notes for Resident #44 documented in part, - 6/24/2022 20:19 (8:19 p.m.) Note Text: Resident alert no respiratory distress noted. Resident came to nurses station with blood on his shirt and nose, bruises and bump (swelling) behind left ear. resident c/o (complains of) pain of left arm. Resident stated he was lying on couch watching TV in the solarium when resident [Room number identifying R37] approached and accused him of messing up his puzzle in the solarium. Nursing supervisor notified who then notified DON (director of nursing) and called 911. Resident sent to ER (emergency room) for evaluation and treatment. - 6/25/2022 00:20 (12:20 a.m.) Note Text: Resident back from [Name of hospital] with the diagnosis of closed fracture of distal end of left ulna, abrasion of nose, closed fracture of nasal bone, closed head injury. New order of Amoxicillin-clavulanate (Augmentin) 875-125mg take 1 tablet by mouth 2 times daily for 7 days. Resident denied pain at this time, back in his room at this time will continue to monitor. - 6/27/2022 16:16 (4:16 p.m.) Note Text: Resident was interview today with DSS (director of social services) about what happened between himself and other resident. Resident told writer what transpired. Resident told writer is feeling much better. Resident told writer he feel safe at [Name of facility] at this time. Resident told writer has no pain. Writer will continue to support resident as needed. The After Visit Summary dated 6/24/2022 for R44 from [Name of hospital] documented in part, .Reason for Visit: Facial laceration, arm injury. Diagnoses: Closed fracture of distal end of left ulna, unspecified fracture morphology, initial encounter, closed head injury, initial encounter, abrasion of nose, initial encounter, closed fracture of nasal bone, initial encounter .Imaging results: Wrist Left PA (postero anterior) lateral and oblique (final result) Redemonstrated mildly displaced ulnar fracture. No additional fracture or dislocation noted. Marked vascular calcifications are present .Forearm complete Left (final result) 1. Distal ulnar fracture 2. Dedicated 4 view study of the wrist is recommended to better evaluate the ulnar fracture and evaluate for underlying distal radial fracture .CT (computed tomography) head without contrast (final result) 1. No acute intracranial abnormality. 2. Right nasal bone fracture appears new compared to the prior exam . Resident #37's (R37) most recent MDS, a quarterly assessment with an ARD of 4/2/2022, the resident scored 15 out of 15 on the BIMS assessment, indicating the resident is cognitively intact for making daily decisions. Section E documented no behaviors. Section G documented R37 requiring supervision with transfers, walking in the room and corridors and locomotion on and off the unit. Section G further documented R37 being not steady but able to stabilize without staff assistance with walking and having no functional limitation in range of motion in the upper or lower extremities. Section G documented R37 using a walker. On 6/27/2022 at 1:56 p.m., an interview was conducted with R37 in their room. R37 was observed to have a staff member sitting outside of the room in a chair monitoring the room. R37 stated that the previous Friday they had a fight with another resident who lived across the hall. R37 stated that the police had come and the social worker had advised them they were going to be moved to another room. R37 stated that they did not understand why they were made to stay in their room and not allowed to go outside to smoke with their friends because they were only trying to defend themselves. R37 stated that the other resident hit them in their chest when they asked them a question and they had to fight back to protect themselves. R37 stated that they were disappointed because they were not able to walk around the facility currently or visit with their friends. When asked about the other resident, R37 stated that it was the resident in the room across the hall with the cast on the arm. R37 stated that they did not know why they had a cast now. R37 stated that the facility staff were making the fight into a bigger deal than it needed to be because they were just trying to defend themselves. The progress notes for Resident #37 documented in part: - 6/28/2022 13:46 (1:46 p.m.) Note Text: Addendum- On 6/24/2022 resident [Room number identifying R44] came to nurses station with blood on his nose, bruises and bump (swelling) behind his left ear. There was also blood on his shirt. Resident [Room number identifying R44] c/o pain on left hand. [Room number identifying R44] stated that he was lying on the couch watching TV in the solarium when above resident [Room number identifying R37] approached and accused him of messing up his puzzle in the solarium. [Room number identifying R44] stated he did not know anything about his puzzle. Then [Room number identifying R37] struck [Room number identifying R44] with his walking cane repeatedly. [Room number identifying R44] stated he used his left arm to cover and protect his face. [Room number identifying R37] then hit his arm too. [Room number identifying R44] ran to nurses station reported writer. Writer called nursing supervisor who then reported to DON and called 911. Resident [Room number identifying R44] was sent to [Name of hospital] ER (emergency room) for evaluation and treatment. - 6/27/2022 23:47 (11:47 p.m.) Note Text: Resident transferred from room [Room number] to [Room number] with all medications and personal belongings. - 6/27/2022 18:25 (6:25 p.m.) Late Entry: Note Text: Resident was interviewed 6/27/22 about what happened between himself and another resident. Resident agreed to move to another room. [Name of Shelter] was contacted to see if they have a placement for resident. Writer left a message. [Name of Shelter] was contacted as well about placement and writer was told no bed is available at this time. -6/27/2022 15:00 (3:00 p.m.) .Behavioral problems are other socially inappropriate behaviors Slammed door on staff when angry and yelling at staff . - 6/27/2022 01:43 (1:43 a.m.) Note Text: Resident called for pain medication for generalized pain at 1:25 am. Writer was on [Name of unit] finishing up with another resident. Writer went to [Name of unit] at 1:30am to give [Name of R37] his Percocet. While checking resident's order to pull medication, resident walked from his room to the nurses station and started yelling and cursing writer out. Resident stated that he had been waiting 15 minutes for someone to come and give him his Percocet. Resident snatched medication out of nurses hand, refused water and told nurse, you drink it. Resident walked back to his room and slammed his door. I followed up with resident immediately and medication was taken. Resident remains in room, lying down. Writer will check on resident soon when he has calmed down to check on his pain. Supervisor notified of outburst. - 6/25/2022 07:19 (7:19 a.m.) Note Text: At 3:45am resident left his room stating his going outside to get fresh air, resident was told to wait until morning which he refused, was also told to sign LOA (leave of absence) which he refused too. Resident stated I'm not in prison, resident was told how unsafe it was to go out at that time of the night. Supervisor was made aware, resident went outside and came back to the unit at 4:10am. He is in his room at this time, will continue to monitor. - 6/23/2022 10:28 (10:28 a.m.) Note Text: Resident and I called [Name of Shelter] and left a voicemail. Resident was provide the number to give them a call later. Writer and I called have been trying to call [Name of Shelter] for the few days with no response. Writer left a voicemail. - 6/16/2022 11:00 (11:00 a.m.) .Behavioral problems are verbal behaviors (screaming, cursing, etc.) Screaming at Writer using foul Language told writer you are an animal go back where you came from with expletives. Slamming his door . - 5/4/2022 21:59 (9:59 p.m.) Physician progress note. Note Text: patient has been agitated, hostile to staff. Psych (psychiatry) deemed patient to have mental capacity discussed with DON. Patient is not safe to stay in the facility as he can be a risk to other residents or staff. - 5/4/2022 09:34 (9:34 a.m.) Note Text: slammed the door in my face. Resident asked if he can put his tray on the treatment cart, I said No, he cannot I asked him politely Can you give it to me please He handed the tray to me and slammed the door in my face. - 5/3/2022 18:13 (6:13 p.m.) Note Text: At approximately 2300 (11:00 p.m.) on 5/2 (5/2/2022), the evening nurse notified this writer that the damaged laptop was no longer working after resident poured water on it. Writer notified the police who returned to the facility at 0700 (7:00 a.m.) on 5/3 (5/3/2022) to document the destruction of property. Police stated that writer would have to go to magistrate independently to request the warrant for misdemeanor destruction of property. Police officers spoke with resident in the presence of the writer. Resident recounted the events of the previous night in great detail until the police asked, what happened with the water and the cart. Resident began stating he knew nothing about that started to become agitated. He stood up and left the interview saying, well if you are going to arrest me then arrest me. I would rather go to jail than be in the ****hole. Resident currently in room alone with 1:1 (one to one) supervision to ensure safety of those around him. Resident's guardian and physician updated on current status. - 5/2/2022 22:04 (10:04 p.m.) Note Text: This wirter [sic] received call from the nurse on resident's unit at approximately 8:45pm. Nurse reported that resident was upset about pain medication being administered every 6 hours instead of every 2 hours and that he was disrupting the unit. Writer could hear resident yelling in the background loudly and calling the nurse obscene names. Nurse reported that resident was slamming doors, yelling loudly and grabbed the unit phone off of the wall. The nurse stated that resident tried to pull the door shut when she attempted to enter to attend to [R37]'s roommate. Nurse also reported that resident intentionally knocked over the ice pitcher on the medication cart, damaging the medication laptop. Writer notified police and they responded to the building. Writer spoke with police officers on site who stated, well there is not much we can do in this setting other than speak with him and document. Police officer reported that resident was calm upon their arrival and denied doing anything the [sic] medication cart. Police officer stated the laptop remained on and working, but that if is [sic] stopped working to call back to document the damage. Increased supervision provided by CNAS (certified nursing assistants) during the remainder of the shift. Writer left message for resident's guardian and physician regarding his behavior. Writer also notified psych (psychiatrist), who stated he would come in the morning to see the resident. The geriatric psychiatry consult note dated 3/10/2022 for R37 documented in part, .asked to evaluate cognition. Pt (patient) is alert & engaging. Fully oriented. He admits he is easily frustrated. He feels staff don't care. He can be very aggressive verbally. Has been known to use racial slurs, hard to direct . The geriatric psychiatry consult note dated 5/3/2022 for R37 documented in part, .Pt has been struggling, he is frustrated he is here. Feels mistreated by staff. Last week was physically aggressive [medical abbreviation for with] behaviors that included breaking a laptop . The comprehensive care plan for R37 documented in part, [Name of R37] is at risk for behaviors (verbal/physical aggression, refusal of care, delusions) r/t (related to) diagnosis of adjustment disorder with disturbance of conduct, mood disorder, psychosis and major depression. Date Initiated: 08/16/2021. Revision on: 11/08/2021. The FRI (facility reported incident) dated 6/25/2022 documented in part, . [Name of R44] reported resident-resident altercation that took place in the second floor solarium between himself and [Name of R37]. Head-to-toes assessment completed, [Name of R44] presented with nose bleed, and a bruise to the back of his neck. [Name of R37] sustained no injury. [Name of R44] transferred to the hospital for further evaluation. Responsible party and Physician notified. Resident send [sic] back to their room under 1:1 observation, one resident send to ED (emergency department) for further evaluation, facility investigation initiated including resident evaluations/interviews, staff interviews and staff education . On 6/28/2022 at 11:05 a.m., an interview was conducted with OSM (other staff member) #10, the director of social services. OSM #10 stated that they were not in the facility on 6/24/2022 when R37 and R44 had the altercation. OSM #10 stated that they were called and made aware of the incident that day and had followed up with both residents on 6/27/2022. OSM #10 stated that R37 had previous behaviors of slamming doors, destruction of facility property and being verbally abusive to staff members but had not displayed any aggression towards another resident that they were aware of prior to that day. OSM #10 stated that they had been attempting to find alternate housing for R37 since they had been to court and deemed competent but had not been able to find a safe discharge location for them. OSM #10 stated that R37 was alert and oriented and had stated that R44 had hit them in the chest first when they had interviewed them on 6/27/2022 regarding the incident. OSM #10 stated that the incident between R44 and R37 was not witnessed by any staff or other residents. OSM #10 stated that since 6/24/2022, R37 had been on 1 to 1 monitoring and staff were with them if they left the room for anything. OSM #10 stated that R44 had never displayed any behaviors and was always a quiet person who enjoyed sitting in the Solarium watching television. On 6/28/2022 at 12:54 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that R37 had anger issues and would throw things at staff when they became angry. LPN #7 stated that there were times when R37 was very pleasant and charming to the staff. LPN #7 stated that they were not aware of any aggression from R37 towards another resident prior to the altercation with R44 on 6/24/2022. LPN #7 stated that they had kept R37 in their room with 1 to 1 monitoring and a chaperone if they left the room since the altercation on 6/24/2022. LPN #7 stated that R44 had never displayed any aggressive behaviors and was always very social and friendly. LPN #7 stated that any resident to resident altercation was intervened upon and the residents were separated and it was immediately reported to the director of nursing or administrator. LPN #7 stated that both R37 and R44 were alert and oriented to person, place, time and situation. On 6/28/2022 at 1:48 p.m., an interview was conducted with LPN #4, unit manager. LPN #4 stated that residents were separated if involved in a resident to resident altercation. LPN #4 stated that the residents would be assessed, EMS (emergency medical services) and police would be notified and they would report the incident to the supervisor and the director of nursing. LPN #4 stated that they would assess the residents depending on the behavior of the residents involved and keep everyone safe. On 6/28/2022 at 2:00 p.m., an interview was conducted with LPN #1, unit manager. LPN #1 stated that R37 would lash out at staff at times and it was like walking on eggshells. LPN #1 stated that R37 had destroyed a facility laptop and did not care. LPN #1 stated that they had to keep other residents out of the way when R37 lashed out at the staff. LPN #1 stated that they were not aware of any incidents with other residents prior to 6/24/2022 with R37. LPN #1 stated that R37 mostly had verbal behaviors that were off and on. LPN #1 stated that they had not had any conversations with R37 since the incident on 6/24/2022. LPN #1 stated that R44 had no history of any behaviors and was always pleasant. On 6/28/2022 at 2:11 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that R37 was competent and had been to court to have the guardianship lifted. ASM #2 stated that R37 had previously damaged a facility laptop when the nurse would not give them additional pain medications. ASM #2 stated that R37 had been placed on 1 to 1 monitoring after the incident on 5/2/2022 when they damaged the facility laptop and displayed behaviors towards staff. ASM #2 stated that the police had come at that time and R37 had lied to the police saying they did not remember anything. ASM #2 stated that R37 did not lack capacity and the police knew they were lying but could not do anything. ASM #2 stated that the previous DON (director of nursing) had moved R37 to a private room and placed them on 1 to 1 monitoring at that time and there had been no further behaviors. ASM #2 stated that they had ended the 1 to 1 monitoring around 5/24/2022 because R37 was not displaying any behaviors and the physician had determined that it could be lifted. ASM #2 stated that they were having the physician fax over a note documenting this. ASM #2 stated that they felt that R37 waited until late on 6/24/2022 after administrative staff had left for the day before approaching R44 in the solarium. ASM #2 stated that on 6/24/2022 after 8:00 p.m., they received a phone call from the facility saying that R44 had been hit with a cane and was going to the hospital. ASM #2 stated that when they arrived R44 had already left for the hospital and R37 was in their room. ASM #2 stated that they spoke with R37 that night they said they did it because R44 touched their puzzle. ASM #2 stated that R37 had cussed me out when they were told they were going to have the 1 to 1 monitoring and going to move to another room. ASM #2 stated that they left the facility prior to R44 coming back from the hospital. ASM #2 stated that they saw R44 on 6/27/2022 with the bruise on the neck, broken nose and arm. ASM #2 stated that they asked R44 why they did not call for help on 6/24/2022 and what happened. ASM #2 stated that R44 explained that R37 thought they messed up their puzzle. ASM #2 stated that R44 would not press charges against R37 because they did not want them to get into trouble. ASM #2 stated that R37's actions were criminal. On 6/28/2022 at 4:36 p.m., an interview was conducted with CNA (certified nursing assistant) #9. CNA #9 stated that they were working on 6/24/2022 when the altercation between R37 and R44 occurred. CNA #9 stated that near the end of the evening shift they were at the nurses station when R44 came up to the nurses station with blood on their nose and said that R37 had hit them with a cane. CNA #9 stated that R44 had told them that R37 had accused them of messing up their puzzle. CNA #9 stated that the nurse had called 911 to send R44 to the emergency room and they had made sure R37 was in their room and monitored 1 on 1. CNA #9 stated that there were no staff or residents who witnessed the incident. CNA #9 stated that R44 normally sat down in the solarium every day watching television. CNA #9 stated that R37 was verbally abusive to staff at times and had slammed doors at times. CNA #9 stated that if a resident to resident altercation was witnessed they immediately separated the residents and called for help. CNA #9 stated that they reported any incidents to the nurse. CNA #9 stated that they reported this because residents could abuse other residents. On 6/29/2022 at 10:08 a.m., an interview was conducted with ASM #5, medical doctor. ASM #5 stated that they care for R37. ASM #5 stated that when R37 gets emotional they could become dangerous and verbally difficult and act out. ASM #5 stated that normally R37 was not dangerous. ASM #5 stated that R37 had destroyed some property but they did not feel that they could give someone a concussion. ASM #5 stated that they had not seen R37 since the incident on 6/24/2022 with R44 but based on what was going on with them they felt that everything was behavioral. ASM #5 stated that they felt that if R37 did not get what they wanted things would keep happening and R37 needed to be safely discharged . ASM #5 stated that they had recommended for the 1 on 1 monitoring to continue and for nursing to keep working on a safe discharge. ASM #5 stated that they felt that R37 did not like R44 for some reason and was mad at them. The facility policy Abuse, Neglect, Exploitation & Misappropriation with a revision date of 11/28/2017 documented in part, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Furthermore, the Administration of The Company recognizes that resident abuse can be committed by other residents, visitors, or volunteers . On 6/28/2022 at 3:48 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the concern for harm. No further information was provided prior to exit. Reference: 1. ulna Of the 206 bones in your body, three of them are in your arm: the humerus, radius, and ulna. this information was obtained from the website: https://medlineplus.gov/arminjuriesanddisorders.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and services according to professional standards to maintain a resident's highest level of well-being, resulting in harm for one of 51 residents in the survey sample, Resident #16. The facility staff failed to implement the proper positioning technique while repositioning Resident #16 in bed on 2/14/19. CNA (Certified nursing assistant) #7 repositioned Resident #16 by grabbing both sides of the resident's torso and pulling on the resident. This improper technique resulted in a right shoulder dislocation and a transfer to the emergency room for a dislocation reduction (returning the shoulder to the normal position) under sedation. The findings include: Resident #16 was admitted to the facility on [DATE]. Resident #16's diagnoses included but were not limited to muscle weakness, heart failure and high blood pressure. Resident #16's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/23/19, coded the resident as being cognitively intact. Section G coded Resident #16 as requiring extensive assistance of two or more staff with bed mobility. Resident #16's quarterly MDS assessment with an ARD of 12/21/18 coded the resident as being cognitively intact. Section G coded Resident #16 as requiring extensive assistance of one staff with bed mobility. Resident #16's comprehensive care plan dated 9/24/18 documented, (Name of Resident #16) has an ADL (activities of daily living) self-care performance deficit r/t (related to) left BKA (below the knee amputation) and burn wounds to right leg .Interventions: BED MOBILITY: (Name of Resident #16) requires extensive assistance by (1-2) staff to turn and reposition in bed at times and at times is able to turn self with use of quarter side rails . Review of Resident #16's clinical record revealed a nurse's note dated 2/14/19 that documented Resident #16 complained of right arm and shoulder pain. The night shift supervisor and physician were notified, a physician order was obtained for an x-ray and the resident was medicated for pain. A right shoulder x-ray dated 2/14/19 documented an anterior dislocation of the humerus (arm/shoulder). Resident #16 was transferred to the emergency room on 2/14/19. An emergency room history and physical dated 2/14/19 documented Resident #16's shoulder dislocation was reduced under sedation. A FRI (facility reported incident) form submitted to the state agency on 2/14/19 documented, Report date: 2/14/19 Incident date: 2/14/19 Describe incident, including location, and action taken: On 2/14/19 resident (name of Resident #16) complained of pain to her right shoulder. Resident medicated for pain and STAT (immediate) x-ray was completed. At approximately 2:30 pm Director of Nursing, (name), received x-ray results showing the resident had an anterior dislocation of the right humerus. MD (Medical doctor) notified and orders received to send resident to the ER (emergency room). DON (Director of nursing) spoke with resident who stated the night CNA 'pulled' her arm to try to get her back in bed. CNA identified as (name of CNA #7). Employee suspended immediately pending investigation. Local police notified . A final FRI report form submitted to the state agency on 2/20/19 documented, Summary of Investigation: (Name of Resident #16) is a [AGE] year old female resident, initially admitted to the Center on 9/14/18. (Name of Resident #16's) medical diagnoses include left BKA amputation, burns to right lower leg, muscle weakness, anemia (a blood disorder), schizophrenia (mental illness), heart failure and chronic obstructive pulmonary disease (lung disease). (Name of Resident #16's) most recent BIMS (brief interview for mental status) (a scale to rate the level of one's cognition) was 14 (on a scale from 0 to 15). (Name of Resident #16) has a low to the floor bed with mats on the floor due to a care planned behavior of crawling out of bed on to the floor. On 2/14/19 at approximately 6:55 am CNA (name of another CNA) entered (Name of Resident #16's) room to provide morning care to her. (Name of other CNA) stated that (sic) asked (Name of Resident #16) if she was ready to get up and (name of Resident #16) replied, 'No way.' (Name of other CNA) asked (name of Resident #16) why she did not want to get up and (name of Resident #16) replied, 'My arm is killing me.' (Name of other CNA) asked what happened to her arm and (name of Resident #16) replied, 'it was how the night aide moved me.' (Name of other CNA) informed the nurse, (name of LPN [licensed practical nurse] #12), who medicated (name of Resident #16) with PRN (as needed) Oxycodone (1). (Name of LPN #12) evaluated (name of Resident #16) and notified the physician, who ordered a STAT (immediate) x-ray of the right arm. After receiving the pain medication (name of Resident #16) told (name of LPN #12) she was 'okay.' (Name of other CNA) stated that after (name of Resident #16) received pain medication she requested to get up into the wheelchair. (Name of LPN #12) notified the night shift supervisor, (name) at approximately 7:10 am saying (name of Resident #16) had a complaint about how the night aide 'positioned her.' (Name of ASM [administrative staff member] #2 [the director of nursing]) arrived at the Center at approximately 7:55 am and went to speak with (name of Resident #16). When (name of ASM #2) asked (name of Resident #16) what happened during the night she replied, 'I don't want to talk about it right now.' (Name of Resident #16) denied pain at that time but was observed holding her right arm close to her body. (Name of ASM #2) spoke with the night shift CNA, (name of CNA #7), regarding what occurred during the night shift with (name of Resident #16). (Name of CNA #7) stated that she pulled the resident up in bed at approximately 1:00 am but that she did not complain of any pain at that time or throughout the night. X-ray of the right shoulder and arm was completed at approximately 12:00 pm. The Director of Nursing received the results at approximately 2:30 pm showing an anterior dislocation of the right humerus. The physician was notified and a new order was received to send the resident to the emergency room for evaluation and treatment. (Name of ASM #2) went to notify (name of Resident #16) of the ordered transfer and speak with her about what occurred. (Name of Resident #16) stated, 'it was the night aide, she pulled me up in bed by my arm.' (Name of Resident #16) stated she was checking on some things in the hallway when the CNA, (name of CNA #7), entered the room and pulled her up in bed by her arm. (Name of Resident #16) stated her roommate was asleep and there was no other employee in the room when this occurred. (Name of ASM #2) notified the local police who responded to the Center and interviewed (name of Resident #16). The police officers asked (name of Resident #16) to explain what occurred during the night shift. (Name of Resident #16) stated the incident occurred around 1:00 am. (Name of Resident #16) stated she was 'checking on somethings (sic) in the hallway,' when the CNA entered the room and 'pulled me up' by her arm. The police officer asked (name of Resident #16) if the CNA was yelling at her or saying bad things to her and (name of Resident #16) replied, 'No, but she wasn't in a good mood.' The police officer then asked (name of Resident #16) if she felt the CNA had intentionally hurt her and (name of Resident #16) replied, Intentionally? No.' The police officer then asked (name of Resident #16) if she felt the CNA 'just got her improperly into bed?' and (name of Resident #16) replied, 'Yes.' On 2/15/19 (name of ASM #2) had an additional interview with (name of CNA #7) regarding the care she provided to (name of Resident #16) during the night of 2/14/19. (Name of CNA #7) stated that at approximately 1:00 am she observed (name of Resident #16's) call light on and she went to the room. Upon entering the room (name of CNA #7) stated she observed (name of Resident #16's) bed very high in the air and she was sitting with her legs dangling near the foot of the bed. (Name of CNA #7) stated that she was concerned (name of Resident #16) was going to fall so she laid her down and then pulled her up in bed by grabbing both sides of her torso. (Name of CNA #7) stated there was no pad or draw sheet underneath (name of Resident #16) to aid in pulling her up in bed. (Name of CNA #7) stated after she positioned the resident in bed and lowered the bed to the floor; (LPN #7) entered the room and provided medication to (name of Resident #16). (Name of CNA #7) stated she checked on (name of Resident #16) every 1.5-2 hours throughout the night and she made no complaints of pain and was observed sleeping during the remainder of the shift. Based on the completed investigation the Center has determined that (name of Resident #16) obtained a dislocation of the right humerus due to improper positioning technique performed by a CNA. Corrective Measures Implemented to Prevent Recurrence: 1. (Name of CNA #7) is no longer employed at the Center. 2. Facility staff re-educated about abuse, neglect, and injuries of unknown origin. 3. Licensed nursing staff re-educated about safe methods to position and reposition residents . A witness statement signed by CNA #7 on 2/14/19 documented, I was assign (sic) to (name of Resident #16). At around 1 AM resident pull (sic) the call light and I went there. I met her at the feet (sic) of the bed and I help (sic) her by putting my hands around her and pull (sic) her up on the bed. A witness statement signed by CNA #7 on 2/15/19 documented, When I came on duty I met the resident. Call light was on and I met the resident sitting on the edge of the bed which is by the feet (sic) side and I (blank space) her down on the bed and I put my hands around her body and I pull her up the bed and I position her while I was doing that the nurse went in the room to give her a medication and I also told her that she was trying to hurt herself. She was putting the bed all the way up and the nurse told me that (sic) the same thing she was doing yesterday which was on Tuesday and I put the bed down and I hide (sic) the bed remote so she will not get to it. Still then, I was been (sic) checking on her not complaind (sic) of any pain until when (name of another CNA) came in the morning. She was dress (sic) her. She came and tell (sic) the nurse that the resident complained (sic) that her shoulder is hurting her. On 1/29/20 at 9:41 a.m., an interview was conducted with Resident #16. Resident #16 was asked to describe the events that occurred in February 2019 when her right shoulder was dislocated. Resident #16 stated, I forgot what happened but I wound up on the floor and an aide came and dragged me by my arm and picked me up and put me back to bed by herself. Resident #16 stated she did not experience pain at that time but later on that same night she was lying in bed and felt pain. Resident #16 stated she told staff something was wrong with her shoulder and the staff obtained an x-ray. On 1/29/20 at 3:42 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 was asked how a resident should be repositioned if he/she was on the edge of the bed at the foot of the bed. LPN #3 stated this depended on the resident. LPN #3 stated she would ask the resident to stand up, move over and sit back down if he/she was ambulatory. LPN #3 stated if the resident required physical assistance, then the staff should call someone to help and use a draw sheet to reposition the resident. LPN #3 stated two staff and a draw sheet should be utilized for a resident who requires physical assistance. LPN #3 was asked if a staff should reach around both sides of a resident and pull them up. LPN #3 stated a staff should not do this because he/she does not want to cause any injury. LPN #3 stated Resident #16 is able to sit up but will call if she needs assistance with positioning. LPN #3 confirmed the assistance of two staff and a draw sheet should be used if Resident #16 is seated at the foot and edge of the bed. On 1/29/20 at 4:19 p.m., an interview was conducted with CNA #5. CNA #5 stated residents' bed mobility and transfer needs are communicated to CNAs via a [NAME]. CNA #5 was asked how a resident should be repositioned if he/she was on the edge of the bed at the foot of the bed. CNA #5 stated the staff member should call for a co-worker and two people should reposition the resident using a draw sheet. CNA #5 stated, You don't pull them up. It's a no no no to pull them with their arms. You can dislocate something or injure them in another way. CNA #5 was asked what should be done if the resident does not have a draw sheet under them. CNA #5 stated a staff member should go get a draw sheet because a resident cannot be pulled by his/her arms. On 1/29/20 at 4:43 p.m., an interview was conducted with ASM #2. ASM #2 was asked to describe the events regarding Resident #16's dislocated right shoulder on 2/14/19. ASM #2 stated she was initially told that Resident #16 reported arm pain so an x-ray was obtained and showed a dislocated shoulder. ASM #2 stated there was no immediate explanation for the cause of the dislocation so Resident #16 was transferred to the hospital and she (ASM #2) began an investigation. ASM #2 stated CNA #7 told her that she entered Resident #16's room and the resident was almost falling off the edge of the bed. ASM #2 stated CNA #7 said she had to get Resident #16 back on the bed and prevent her from falling. ASM #2 stated CNA #7 said there was no pad or draw sheet on the bed and the bed was in a high position so CNA #7 grabbed Resident #16's waist on each side, pulled the resident up then put the bed in a low position and removed the bed remote. ASM #2 stated she asked CNA #7 why she didn't just lower the bed and get help instead of pulling the resident up or tell the resident to sit and yell for someone to help. ASM #2 stated CNA #7 only provided the response that the situation was critical. ASM #2 stated CNA #7 was terminated due to the improper positioning technique and because there was inconsistencies in her story. When asked to elaborate, ASM #2 stated CNA #7 said she got Resident #16 repositioned in bed then the nurse came in to administered medications but the nurse said Resident #16 was in a sitting position when she administered medications. ASM #2 stated Resident #16 said the CNA pulled her up in bed and the resident was reliable, alert and oriented. ASM #2 confirmed CNA #7 used an improper positioning technique. When asked what should have been done, ASM #2 stated a resident should be repositioned by two people using a draw sheet, pad or moving device; not by grabbing his/her body and physically moving him/her. ASM #2 was asked if this technique should be used even when a resident is on the edge of the bed. ASM #2 stated CNA #7 could have repositioned the resident's legs back on the bed and get staff to assist or stand with the resident and yell for help. ASM #2 stated she thought there were other ways the CNA could have repositioned Resident #16 without hurting her. ASM #2 was asked for the facility policy or standard of practice regarding positioning. ASM #2 stated she would look and the best practice is to have two people at all times for the safety of the resident and proper body mechanics for the staff. On 1/29/20 at 5:01 p.m., an interview was conducted with LPN #12 (the nurse caring for Resident #16 during the night shift on 2/14/19). LPN #12 stated that between 12:00 a.m. and 2:00 a.m. she was completing rounds and CNA #7 was in the room with Resident #12 and providing care. LPN #12 stated Resident #16 was lying down on the bed during her observation. LPN #12 stated a couple hours later, at approximately 5:15 a.m. or 5:30 a.m., a CNA told her that Resident #16 was complaining of her arm hurting. LPN #12 stated she talked to the resident who told her that her right arm and shoulder was hurting so she administered pain medication to the resident and notified the supervisor. LPN #12 stated someone else notified the physician and obtained an x-ray. On 1/29/20 at 5:10 p.m., another interview was conducted with ASM #2. ASM #2 stated she could not access Resident #16's [NAME] from February 2019 (because the [NAME] is updated when the resident's condition changes) and the facility did not have a policy or standard of practice (from [NAME]) regarding positioning. On 1/29/20 at 5:39 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern and the concern for harm. On 1/30/20 at 10:18 a.m., an interview was conducted with OSM (other staff member) #7 (the rehab director). OSM #7 was asked how a resident should be repositioned if he/she was on the edge of the bed at the foot of the bed. OSM #7 stated if the resident has any lower extremity strength then staff could help the resident scoot to the head of the bed and assist the resident with lying down but this depended on the resident's needs. OSM #7 was asked if a staff member should put his/her hands on each side of a resident's torso and pull the resident up. OSM #7 stated staff should use a transfer gait belt or just guide the resident with contact guard by placing his/her hands on the resident's torso. OSM #7 stated she would not grab a resident up by under the resident's arms and confirmed this is not a preferred or proper technique. Review of an employee corrective action form revealed CNA #7 was terminated on 2/21/19. Review of education in-service attendance records revealed nursing staff was educated regarding resident positioning from 2/15/19 through 2/17/19. Education of the nursing staff was verified via multiple interviews during the survey. No other concerns regarding positioning were identified during the survey. No further information was presented prior to exit. PAST NON-COMPLIANCE REFERENCE: (1) Oxycodone is used to treat pain. This information was obtained from the website: https://medlineplus.gov/ency/article/007285.htm