F0725

E

Insufficient Nursing Staff Leading to Delayed Medication Administration

Bloomfield Hills, Michigan Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure sufficient nursing staff on the 2 [NAME] Unit, resulting in residents not receiving medications according to physician orders. A complaint alleged that on the evening of 12/25/25, the unit was short staffed from 7:00 PM to 11:00 PM, with no nurse present during that time and residents not receiving medications timely. The complainant reported that staff said help would be sent, but no one arrived until 11:20 PM. During interviews, the Staffing Coordinator stated that two night nurses had called in and that nurse managers came in to cover, including a salaried unit manager who was not required to punch in. The Administrator and Staffing Coordinator later identified nurses assigned to the unit based on an assignment sheet, but time punch records did not fully support those assignments.

Review of the 12/25/25 assignment sheet for the 2 [NAME] and 2 East Units showed that a unit manager LPN and another LPN were assigned from 7:00 PM to 11:00 PM, and a unit manager RN and another RN were assigned from 11:00 PM to 7:00 AM, with the RN also listed as assigned to 2 East during the same time. Time punch records revealed that the LPN listed for 7:00 PM to 11:00 PM had actually punched out at 8:59 PM, and the salaried LPN unit manager had no time punch. The RN unit manager assigned from 11:00 PM to 7:00 AM did not punch in until 11:15 PM, and the other RN assigned to that shift punched out at 11:45 PM. No missed punch documentation was provided to reconcile these discrepancies, and the facility could not produce evidence of the exact hours worked by the nurse managers.

Record review of residents on the 2 [NAME] Unit showed that three residents had multiple medications scheduled for administration at 9:00 PM on 12/25/25, including atorvastatin, Colace, Eliquis, metoprolol tartrate, tizanidine, divalproex sodium, Voltaren gel, Lantus insulin, and gabapentin. All of these 9:00 PM medications for the three residents were documented as administered by the RN unit manager who did not punch in until 11:15 PM, more than two hours after the scheduled administration time. During interview, the DON stated he had not been aware of staffing challenges that day, while the ADON reported that nurse managers came in. The RN unit manager later reported she had come in early but did not punch in until 11:15 PM and had not requested a missed punch because she was a manager, and she could not provide evidence of her arrival and departure times. The facility reported that corporate staff were unable to access an audit report of medication administration times, and no further documentation was provided before the end of the survey.