F0607

D

Failure to Investigate and Report Resident-to-Resident Abuse Incident

Marquette, Michigan Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to fully implement its Abuse Program Policy and Procedure by not immediately identifying, documenting, and thoroughly investigating an incident of resident-to-resident abuse involving two residents. An anonymous complaint to the State Agency reported that one resident aggressively grabbed another resident’s head, that two nurses intervened, and that both nurses called the DON immediately after the incident. The complaint further alleged that the NHA later stated he had watched video footage and characterized the interaction as the resident ‘petting’ the other resident’s head, and that the incident was not reported by the facility as resident-to-resident abuse.

Resident #82 was admitted with Alzheimer’s disease and had a MDS BIMS score indicating severe cognitive impairment. Behavior charting and EMR progress 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, aggressive behavior with staff during care, hitting staff, backhanding a CNA across the face and grabbing an arm leaving red marks, and multiple episodes of combative behavior causing staff injury. On 12/6/25 at 17:00, behavior charting documented that this resident, while getting ready to eat dinner and standing next to Resident #90, put his hands over her hair/eyes. LPN S, who wrote this note, later stated that the resident grabbed the other resident’s head, that it was not gentle, and that the two residents were immediately separated. LPN S also reported that a phone call was made to the DON to report the incident because the resident was known to have extremely aggressive behaviors.

Resident #90 was also admitted with Alzheimer’s disease and had a MDS BIMS score of 0/15, indicating cognitive impairment. EMR progress notes for this resident from 10/1/25–12/12/25 contained no documentation of any aggressive physical or verbal interaction with other residents and no documentation that Resident #82 touched or grabbed her head on 12/6/25. The record also showed that Resident #90 was elderly, blind, hard of hearing, and receiving hospice care, and a hospice social worker note described her as asleep, peaceful, and not arousing to verbal or gentle touch during a visit shortly before the incident period. Despite the facility’s written Abuse; Investigative and Reporting policy requiring immediate (within two hours) reporting and investigation of all alleged or suspected abuse, completion of an Unusual Occurrence Report by the charge nurse, notification of the Administrator, and reporting allegations of abuse to the State Agency within 24 hours, the NHA acknowledged being aware of the situation between the two residents about a month prior and reported that he did not complete an Unusual Occurrence Report or a Facility Reported Incident. The investigation checklist and policy requirements for interviews, record review, and documentation were not shown to have been followed for this incident, and there was no corresponding documentation in Resident #90’s record, demonstrating the facility’s failure to fully implement its abuse investigation and reporting procedures.