F0609

D

Failure to Timely Investigate and Report Resident‑to‑Resident Physical Altercations

Flint, Michigan Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly and thoroughly investigate and report two resident‑to‑resident physical altercations, and to document and follow up on the affected residents’ status, as required by facility policy and federal and state law. In the first incident on 12/7/25, one resident (R402) struck another resident (R403) three times in the face in the first‑floor dining room while R403 was seated and unable to fight back. A CNA intervened, was punched in the face by R402, and reported that R402 then attempted to strike other residents and staff. The facility’s risk management report documented that the DON was notified approximately two hours after the incident. Despite staff witnessing the altercation and observing apparent facial bruising on R403, the abuse coordinator determined the event was not reportable, concluding that abuse was not substantiated because R403 was considered unharmed and gave a thumbs‑up when asked if he was okay.

R403’s clinical record showed significant cognitive impairment and multiple psychiatric and neurologic diagnoses. His BIMS score was 0/15, indicating severe cognitive impairment, and he had a history of hemiplegia and hemiparesis after an intracranial bleed, major depression, and anxiety disorder, and was receiving paroxetine, divalproex, and Seroquel. Despite this vulnerability and the reported facial bruising, there were no progress note entries, follow‑up assessments, physician or NP evaluations, or psychiatric referrals documented for R403 between 12/8/25 and 12/30/25 related to the altercation. The corporate nurse and DON confirmed that no post‑incident documentation or follow‑up assessments were entered in R403’s record. The facility’s Verification of Investigation Summary for this incident was not completed until 2/5/26, approximately 60 days after the event, and the incident was not reported to the state FRI submission site, contrary to the facility’s abuse policy requiring prompt investigation and immediate reporting, but not later than two hours after an alleged violation is made.

The second incident occurred on 12/27/25 and involved another resident (R401) and the same aggressor resident (R402). Nurse’s notes documented that R401 was attacked in the day room by R402, who entered very angry and agitated, struck R401 in the face, and knocked off her glasses. A CNA responded to calls for help and found R401 on the floor next to her chair, with R402 at the edge of his wheelchair over her, arms in motion as if to strike; she separated them and assisted R401 back to her chair, then reported the event to the nurse and 911 was called. The nurse documented that R401 was “scared to death,” and the police report recorded that R401 stated she had been punched in the face, with the officer observing slight redness on the right side of her face. The officer’s report also documented that when asked if he punched R401, R402 answered yes and mimed a punching motion. R401, who had a BIMS score of 13/15 (cognitively intact) and diagnoses including bilateral knee osteoarthritis, PTSD, major depressive disorder, schizophrenia, and anxiety disorder, later told the surveyor she was hit 10–12 times, pulled from her chair, kicked on the floor, bled from her mouth, and was afraid to leave her room afterward.

Despite these accounts, the DON and Administrator/Abuse Coordinator concluded that no abuse occurred and deemed the incident not reportable, stating there was no witness that R401 was assaulted. The DON did not begin the facility risk management documentation and investigation until 1/2/26, seven days after the incident, and the Verification of Investigation Summary was not completed until 1/27/26, 31 days after the event. Staff reported that written statements about the incident had been completed and turned over to management, but the DON was unable to locate them when requested by the surveyor. One nurse who documented the incident reported receiving verbal education and a write‑up from management about her documentation and did not answer when asked if she had been asked to change, modify, or delete her note. The facility did not submit either of the two resident‑to‑resident altercation incidents to the state FRI submission site, despite its written abuse policy stating that all abuse allegations, including resident‑to‑resident altercations and injuries of unknown source, must be promptly and thoroughly investigated and reported immediately, but not later than two hours after the alleged violation is made.