F0740

D

Failure to Provide Timely Behavioral Health Follow-Up After Resident-to-Resident Altercation

Flint, Michigan Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely behavioral health assessments and services following a witnessed resident‑to‑resident physical altercation. On 12/7/25, a CNA observed one resident (R402) strike another resident (R403) in the face three times while R403 was seated in the dining room. The CNA intervened, was struck in the face by R402, and reported that after the residents were separated, R402 began swinging at other residents and staff. A facility Risk Management Report documented that R403 was hit in the face three times by another resident while in the dining room and that he was unable to provide a description of the event.

R403 had a BIMS score of 0/15, indicating severe cognitive impairment, and diagnoses including hemiplegia/hemiparesis after intracranial bleed, major depression, and anxiety disorder, and was receiving paroxetine, divalproex, and Seroquel. R402 had a BIMS score of 11/15, indicating mild cognitive impairment, and was receiving Seroquel, Depakote, and sertraline for dementia with psychotic/agitated behaviors, mood stabilization, and depression. Despite the altercation and reported visible facial bruising on R403, review of both residents’ clinical records from 12/7/25 through 12/30/25 showed no post‑assault nursing or provider assessments, no documentation of physical findings such as redness, bruising, or discoloration, no assessment of pain, and no progress notes addressing either resident’s physical, social, or emotional status related to the incident.

Record review further showed that no timely behavioral health or social services interventions were initiated for either resident after the incident. There was no evidence of psych referrals, evaluations, or therapy referrals for the post‑incident period for either resident, and no social services documentation or visits addressing the altercation for the entire month of December. The Social Services Director acknowledged she did not see R402 after the incident, did not send referrals after the physical altercation, and was unaware of or did not remember being informed of the event involving R403. The facility’s Behavior Management Program policy, which calls for behavior management team involvement for residents with reportable incidents and behaviors harmful to others or interfering with function or care, was not implemented for these residents following the 12/7/25 altercation.