F0710

D

Lack of Timely Physician Assessment After Resident-to-Resident Altercation

Fenton, Michigan Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely physician assessments and documentation for two residents following a resident-to-resident physical altercation that resulted in facial injuries. On the morning of 10/18/2025, two residents engaged in an altercation near the facility café while in line, during which one resident struck the other in the face. A nurse (Nurse W) encountered the residents immediately afterward, separated them, and assessed both for injuries. Nursing documentation for both residents on 10/18/2025 described new in-house acquired facial abrasions that were bleeding, which were cleaned with normal saline and left open to air, and indicated that the physician (Physician U) was notified.

For the first resident, who had diagnoses including Alzheimer’s dementia, diabetes, depression, kidney failure, hypertension, gout, GERD, and a history of falls, the MDS showed intact cognition with a BIMS score of 15/15 and a need for some assistance with care. Nursing notes documented scratches to the nose and face, and a Skin & Wound Evaluation recorded a new facial abrasion measuring 0.6 cm by 0.4 cm that was bleeding. Although the wound note indicated the physician was notified, the subsequent physician visit note dated 10/20/2025 listed the chief complaint as “altercation with a resident” but did not mention that the resident had been hit in the face, did not describe the facial wound, and did not document a physical assessment of the injury. The resident’s behavior care plan referenced involvement in a resident-to-resident physical altercation but did not mention that the resident was injured.

For the second resident, who had diagnoses including autism, mild intellectual disabilities, epilepsy, mood disorder, restlessness and agitation, heart disease, history of stroke, peripheral vascular disease, gout, and hypothyroidism, a prior care transition note indicated moderately impaired cognition with a BIMS score of 12/15. Nursing documentation on 10/18/2025 described scratches to the left side of the face, and a Skin & Wound Evaluation recorded a new in-house acquired abrasion on the left cheek measuring 3.3 cm by 1.6 cm that was bleeding and had been cleaned, with notation that the physician was notified. A physician visit note dated 10/20/2025 listed the chief complaint as “altercation with other resident” but did not mention a skin assessment or that the resident had been hit in the face. A later provider note on 10/30/2025 documented a skin inspection with “no rash or lesions,” but there was no earlier physician assessment of the facial injury. Surveyors determined there was no physician or provider assessment of either resident’s injuries from the 10/18/2025 altercation until 10/30/2025, and the facility’s policy stated that each resident’s medical care is under the supervision of a licensed physician who participates in assessment and care planning and monitors changes in medical status.