F0725

G

Insufficient Night-Shift Nursing Staff Led to Delayed EMS Transfer After Acute Change in Condition

Bridgman, Michigan Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure sufficient licensed nursing staff on the night shift to meet resident needs and maintain residents’ highest practicable well-being, which contributed to a delayed emergency transfer for a resident who experienced an acute change in condition and later died. The facility used a corporate staffing matrix based solely on census, without documented consideration of resident acuity, despite a facility assessment stating that staffing levels would be based on acuity and diagnoses. On the night in question, the census was 75, and the staffing matrix and facility assessment both indicated there should be three nurses on the night shift; however, only two nurses (one of whom was still in orientation) were on duty for the entire overnight shift after a scheduled nurse called in. The DON acknowledged that the facility often worked with only two nurses at night and believed three nurses were not needed after the evening medication pass, and the staffing manager confirmed that when there was a call-in, a day-shift nurse might stay over only long enough to complete the evening medication pass, leaving the night shift short.

Resident #1 was a female resident with bipolar disorder, dementia, and delusional disorder. On the cited night, two residents, including Resident #1, required transfer to the hospital. CNA interviews described that staffing on nights was frequently short, with only two nurses and five CNAs at times, and that the south and east (back) units had higher-acuity residents, many of whom required two staff for care. CNAs reported that when CNAs working 8‑hour segments left mid‑shift, remaining CNAs were left with 15–16 residents each, and that residents sometimes waited 20 minutes or more for call lights to be answered, especially when showers were being completed. One CNA stated that once staff were in the back units, they did not go to other parts of the building due to the high acuity and needs of those residents.

During the night in question, the two nurses on duty were RN V, who was still completing orientation, and RN P, who was assisting RN V with orientation tasks, including learning how to transfer a resident to the hospital. According to RN V, around 3:00 a.m. two residents, including Resident #1, needed to be transported to the hospital. RN V reported that she had earlier transferred another resident that night and had learned that EMS would not wait if paperwork was not ready, so she took extra time to complete all transfer paperwork correctly for Resident #1. She stated she asked RN P whether they should call 911, and RN P told her to finish the paperwork while RN P went to eat and would help afterward. RN V believed RN P called 911; however, she later stated she did not call 911 herself. RN P, in contrast, initially stated she did not call 911 and then expressed uncertainty about who had called. Documentation by RN V, entered later that morning, indicated that at 3:16 a.m. the PA was notified of Resident #1’s change in condition (hypotension, lethargy, cool skin, significant bilateral lower-extremity edema, and fluid-filled blisters on the heels), that the PA agreed the resident required hospital evaluation, and that the hospital was notified and preparations for transfer were initiated.

EMS and 911 records showed that 911 received a call at 3:20 a.m. for another resident, with that call clearing at 5:01 a.m., and that an abandoned call from the facility occurred at 5:24 a.m., which was returned and staff reported no emergency. At 5:29–5:30 a.m., the local emergency department and the ambulance service contacted 911, reporting that the facility had called the hospital with report on a patient over an hour earlier but the patient had not arrived, and that the facility had reported difficulty reaching 911 due to phone issues. A subsequent call detail report documented that 911 initially closed the call after being told there was no emergency, then reactivated it when the ambulance service called back with information that a 77‑year‑old female at the facility was hypertensive, unresponsive, and in cardiac arrest, and that the facility said they could not get through to 911. EMS was dispatched around 5:37 a.m. and arrived to find the resident unconscious but breathing with a pulse, on oxygen via nasal cannula, with no CPR or ventilations in progress. EMS documented severe hypoxia requiring escalation of oxygen support and transported the resident to the emergency department.

Hospital records indicated that upon arrival to the emergency department, the resident was comatose, hypotensive, tachycardic, cool, and cyanotic, and was intubated, with crushed pill remnants noted in the back of the throat and concern for polypharmacy versus aspiration of medication. The resident was found to have a UTI and developed complications including unstable SVT, cardiogenic shock on top of sepsis, and DIC, ultimately leading to death later that day. The facility’s own data for the date of the incident showed that, with a census of 75, 35 residents required two or more staff for care such as transfers. Multiple CNAs and nurses reported that night shifts were often short-staffed, that there were not enough nurses to cover nights, and that they frequently did not get lunch breaks. The combination of working with only two nurses instead of the three indicated by the facility’s matrix and assessment, the high acuity and dependency of many residents, and the orientation status of one of the two nurses on duty contributed to delays and confusion in arranging timely EMS transport for Resident #1 after an acute change in condition.