F0609

D

Failure to Report Suspected Abuse Related to Forced Shower and Resulting Leg Fracture

Marshall, Michigan Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report to the state agency an allegation of abuse related to a resident who was an older adult with Alzheimer’s disease, bipolar disorder, dementia, and anxiety. The resident had been admitted and later returned to the facility, and subsequently expired with a physician-documented time of death of 3:34 PM (actual time 2:34 PM). On the day of death, a progress note documented that the ADON was on the phone with the resident’s guardian discussing a change in condition and an assessment by the Medical Director when two CNAs reported they believed the resident had passed away. The ADON assessed the resident and found her unresponsive, with fixed eyes, no visible breathing, no lung sounds, and no apical pulse after a full 60‑second check, and the Medical Director then confirmed death at 2:34 PM.

Prior to the resident’s death, there was an incident during a scheduled shower in which the resident, who repeatedly stated she did not want a shower, became combative. CNA F and CNA G reported that the resident was yelling, digging into their skin, hitting, and kicking while being transferred with a mechanical lift and placed on a shower chair. Both CNAs documented that the resident did not want the shower and that she kicked bars in the shower area, resulting in bruising. CNA F stated she was told by RN H that the resident had to receive a shower or she would be written up, and that she held the resident’s arms down by the wrists while CNA G washed the resident. CNA G confirmed that the resident was very irate, kicking, and that she saw CNA F holding the resident’s wrists down while the resident continued to say she did not want the shower, and later stated she considered both the forced shower and the wrist‑holding to be abuse.

Clinical documentation and staff statements showed that after the shower incident the resident had bruising, swelling, and an abrasion to the right shin, with swelling from knee to ankle, guarding of the leg, yelling out with touch, and refusal of ROM of the knee. An X‑ray later revealed an acute transverse fibular neck fracture of the lower leg. The DON’s progress note to the guardian indicated that during the shower the resident became aggressive and hit her leg on the shower chair, causing a bruise, and that an X‑ray was ordered. The guardian reported being told that the resident had been hostile during the shower and had kicked a bar on the wall, and that she was later notified of a bruise and then of the resident’s death, without prior calls about a change in condition. Despite CNA F’s written statement and CNA G’s characterization of the incident as abuse, the Administrator stated she was not able to substantiate abuse and therefore did not report the incident to the state agency, resulting in the failure to report suspected abuse as required.