F0600

G

Failure to Protect Resident From Physical Abuse and Address Psychosocial Impact After Resident‑to‑Resident Assault

Rochester Hills, Michigan Survey Completed on 02-25-2026

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 address the abused resident’s subsequent psychosocial needs. On the evening of 1/10/26, one resident who ambulated without a device was walking in the hallway when another resident, who used a wheelchair, appeared to roll over the ambulatory resident’s foot. Witness statements from a CNA and an LPN indicated that the ambulatory resident then came around behind the wheelchair user near the elevator and punched the wheelchair user in the nose with a closed fist, causing immediate nasal bleeding, crying, and visible distress. The assaulted resident verbally stated that the other resident had hit her, and the aggressor resident was heard saying, “No, I meant to do it. These people are always touching me and rubbing on me. I'm tired of it.” The aggressor resident later told the NHA, DON, and surveyor that he had “knocked her in the face” or “punched her in the nose” after she ran over his foot or grabbed his pants, and acknowledged feeling angry and not liking to be touched.

The assaulted resident had multiple diagnoses, including vascular dementia, generalized anxiety disorder, bipolar disorder, prior subarachnoid hemorrhage, muscle wasting, and malnutrition, and was severely cognitively impaired per a BIMS score of 6/15. Following the punch, she was emergently transferred to the hospital, where imaging confirmed bilateral nasal bone fractures. Progress notes and pain logs documented pain rated 10/10 requiring additional PRN acetaminophen, as well as visible anxiety and refusal of vital signs at the time of transfer. A subsequent physician note confirmed recent nasal fractures from being struck by another resident, described a small bruise on the bridge of the nose, and noted ongoing pain management with acetaminophen and morphine. The physician also documented that the resident was experiencing an acute psychotic episode with delusions and agitation in the context of recent trauma and hospitalization.

The aggressor resident also had significant cognitive and psychiatric diagnoses, including dementia, schizophrenia, diabetic neuropathy, and an adjustment disorder with anxiety, and had a BIMS score of 6/15. Facility records showed a prior resident‑to‑resident assault by this same resident on another female resident months earlier, in which he struck her with a closed fist and police were contacted, with 15‑minute checks implemented for 48 hours. Despite this history and the facility’s abuse policy defining physical abuse as willful infliction of injury by non‑accidental means (including hitting and punching) and requiring immediate protection of residents and care plan revision when needs change as a result of abuse, the investigation documents indicated the facility did not verify that abuse occurred in the 1/10/26 incident. Additionally, review of the assaulted resident’s care plan showed no updates to address protection or psychosocial concerns after the event, even though the resident later reported feeling terrible about the incident, described ongoing head and ear pain, recounted bruising and attempts to cover it with makeup, and stated she did not feel safe in the facility and wanted to go home. A police report classified the event as a simple assault/battery, documented the aggressor’s admission that he punched the victim once in the face, and verified that a facility nurse witnessed the punch.

The facility’s own abuse and neglect policy, updated 6/18/25, stated that abuse includes willful infliction of injury such as hitting and punching, and that any person, including other residents, may be a potential aggressor. The policy required immediate steps to assure resident protection and revision of the resident’s care plan if medical, nursing, physical, mental, or psychosocial needs changed as a result of an incident of abuse. In this case, the documented willful punch to the face by one resident against another, resulting in nasal fractures, severe pain, anxiety, and later expressed fear and lack of safety by the victim, along with the absence of care plan revisions to address the victim’s psychosocial needs, formed the basis of the deficiency for failure to protect the resident from abuse and to respond appropriately to the consequences of that abuse.