F0600

G

Failure to Protect Residents From Repeated Resident‑to‑Resident Physical Abuse and to Report and Assess Incidents

Flint, Michigan Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from physical abuse and to respond appropriately to resident‑to‑resident altercations involving one resident with a history of agitation and two other residents. In the first incident, a cognitively impaired resident with a BIMS score of 0 was sitting in the first‑floor dining room when another resident, described by staff as easily agitated, swearing, yelling, and unpredictable, came into the area and struck him in the face three times. A CNA witnessed the assault, intervened, and was punched in the face by the aggressor, who then attempted to swing at other residents and staff. Staff reported visible bruising to the victim’s face and overhead paging for help, but there was no documentation in the victim’s medical record of any post‑incident nursing assessment, description of injuries, pain assessment, or physician/NP/PA evaluation, and no psych or therapy referral was documented for either resident following this event.

The same aggressor resident, who had mild cognitive impairment (BIMS 11) and was receiving psychotropic medications for dementia‑related psychotic/agitated behaviors and mood stabilization, was involved in a second altercation with another resident who was cognitively intact (BIMS 13) and had diagnoses including PTSD, major depressive disorder, schizophrenia, and anxiety disorder. In this second incident, the cognitively intact resident reported being assaulted multiple times in the head while seated in a day room, with her glasses knocked off and being pulled from her chair and kicked on the floor. A CNA responded to calls for help and found the victim on the floor next to her chair with the aggressor at the edge of his wheelchair, arms in motion as if to strike, and separated them. Nurse’s notes documented that the resident was attacked in the day room, and a police officer later documented slight redness on the victim’s face and that the aggressor admitted punching her. Subsequent nursing notes recorded blood on the victim’s sheets, a slightly loose tooth with old blood around it, and later a pain score of 10/10, but there was no detailed documentation of pain location, quality, or specific pain interventions.

Across both incidents, the facility failed to follow its abuse policy requiring prompt, thorough investigation and immediate reporting of abuse allegations. For the first incident, the DON was notified approximately two hours after the event, and the facility did not complete its Verification of Investigation Summary until 60 days later. For the second incident, the DON was notified by phone on the day of the event but did not complete the risk management documentation and investigation until several days later, and the Verification of Investigation Summary was not completed until 31 days after the incident. The abuse coordinator and DON determined both incidents were not reportable and unsubstantiated, despite a staff‑witnessed assault, observed injuries, and a police report documenting the aggressor’s admission to punching the victim. There was no timely psych or behavioral referral documented for the involved residents after either incident, and the social worker reported not being informed of the first incident and learning of the second incident nearly a week later, resulting in no immediate psychosocial follow‑up for the victims. The facility’s own policy required that abuse allegations be reported immediately, but the administrator later acknowledged that both resident‑to‑resident physical altercations should have been reported and taken seriously by the abuse coordinator.