F0600

D

Failure to Protect Resident From Peer Abuse and to Report/Investigate Incident

Marquette, Michigan Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident and to follow its own abuse reporting and investigation policies. An anonymous complaint to the State Agency alleged that one resident aggressively grabbed another resident’s head, and that staff intervened between the two. The complaint further alleged that two nurses reported the incident to the DON, and that the NHA later stated he had watched video and characterized the action as the aggressor resident “petting” the other resident’s head, and that the incident was not reported by the facility as a resident-to-resident event. The NHA later reported to the surveyor that he was aware of the situation between the two residents about a month prior but did not complete an Unusual Occurrence Report or a Facility Reported Incident to the State Agency.

Resident #82 was admitted with Alzheimer’s disease and had a BIMS score indicating severe cognitive impairment. Behavior charting and EMR notes documented a pattern of aggressive behaviors by this resident around the time of the incident, including aggression toward others, raising fists in a threatening manner at an activity aide, following a female resident and placing a hand on her back in a way that upset her, being aggressive and combative with staff during care, backhanding a CNA across the face and grabbing an arm leaving red marks, and multiple instances of hitting, punching, spitting, and pushing staff, with some incidents causing staff injury. A hospice RN documented that this resident had experienced agitation involving violence toward other residents, and facility documentation noted increasing behaviors and agitation resulting in fear, discomfort, agitation, anger, and dangerous actions toward care staff, as well as difficulty redirecting the resident and identifying techniques to keep staff safe.

Resident #90 was also admitted with Alzheimer’s disease and had a BIMS score indicating cognitive impairment. The resident was described as elderly, blind, hard of hearing, and on hospice care. A hospice social worker note shortly before the incident described this resident as asleep in a wheelchair in the dining room, appearing comfortable and peaceful, and not arousing to verbal or gentle touch. On the date of the alleged head-grabbing incident, behavior charting for Resident #82 documented that he was standing next to Resident #90 and put his hands over her hair/eyes. LPN S, who authored this behavior note, later reported that Resident #82 grabbed onto Resident #90’s head, that the two residents were immediately separated, and that a phone call was made to the DON to report the incident because Resident #82 was known to have extremely aggressive behaviors. LPN S stated that when Resident #82 grabbed Resident #90’s head, it was not gentle. However, review of Resident #90’s EMR progress notes over the relevant period showed no documentation of any aggressive physical or verbal interaction with other residents and no documentation of Resident #82 touching or grabbing her head on the date in question.

The facility’s written policy on abuse investigation and reporting required that all alleged violations involving mistreatment, neglect, or abuse, including resident-to-resident incidents, be immediately addressed, that an Unusual Occurrence Report be completed by the charge nurse for all allegations or suspicions of abuse, and that allegations of abuse of any nature be reported to the State Agency within 24 hours of the incident. The policy also outlined steps for investigation, including interviews, record review, and documentation of the event. In this case, despite staff reporting that Resident #82 grabbed Resident #90’s head and the facility’s knowledge of Resident #82’s ongoing aggressive behaviors toward others, the NHA acknowledged that no Unusual Occurrence Report or Facility Reported Incident was completed, and there was no documentation of the incident in Resident #90’s record. Based on the reasonable person concept, the surveyors determined that Resident #82’s action of grabbing Resident #90’s head would cause feelings of pain, fear, and intimidation, and that the facility failed to protect Resident #90’s right to be free from physical abuse by another resident and failed to follow its own abuse reporting and investigation procedures.