F0692

E

Failure to Provide Timely Bedside Water to Multiple Residents

Detroit, Michigan Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to provide timely bedside water to multiple residents, as required to maintain adequate hydration. During the initial screening on 1/27/2026 between 10:00 a.m. and 2:00 p.m., several residents were observed without water in their rooms or at bedside, despite the facility’s oral hydration policy stating that each resident will be provided bedside water. One resident (R94), who was cognitively intact with a BIMS score of 14/15 and had diagnoses including hemiplegia/hemiparesis after cerebral infarction and hypertension, reported that no fresh water had been passed since about 9:00 p.m. on the midnight shift and showed a small iced tea bottle they were using to obtain water from the sink. Another cognitively intact resident (R76), with diagnoses including cerebral infarction, hypertension, and venous insufficiency, was observed in bed with an empty Styrofoam cup out of reach and stated that no cold water had been passed since the midnight shift.

A third resident (R18), who had severe protein-calorie malnutrition, dementia, anemia, type 2 diabetes mellitus, and cerebral infarction and was severely cognitively impaired with a BIMS score of 3/15, stated that no one had brought any fresh water at all that day and expressed a desire for cold water. Another resident (R156), cognitively intact with a BIMS score of 15/15 and diagnoses including congestive heart failure, chronic respiratory failure, type 2 diabetes mellitus, and COPD, reported that staff had picked up their water cup around breakfast time and had not brought any fresh water back. A further resident (R62), cognitively intact with a BIMS score of 15/15 and diagnoses including ETOH use, left femur fracture, hypertension, history of falls, carotid artery disease, and COPD, was observed at 1:30 p.m. with no water cup in the room or at bedside and declined interview.

Review of staffing assignments showed that CNA T was assigned to several of the affected residents (R62, R76, and R18) on the 7:00 a.m. to 3:00 p.m. shift. At 3:00 p.m., CNA T acknowledged that water had not been passed and stated they planned to pass water later, adding that residents should have had water at the start of the shift. Another CNA (CNA U), assigned to other affected residents (R156 and R94) and working an additional four hours, stated at 4:16 p.m. that they had been very busy and were only then passing water, acknowledging that residents should have received fresh water earlier. The DON later confirmed that staff are expected to pass fresh water multiple times on 12-hour shifts and that on 8-hour shifts fresh water should be passed before 3:00 p.m. and 5:00 p.m., usually by 10:00 a.m., and that fresh water should be passed before 3:00 p.m. regardless, which had not occurred for these residents on the day in question.