F0550

E

Unattended Unit Leaves 41 Residents Without RN Coverage and Missed 6 AM Med Pass

Flint, Michigan Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The deficiency involves a nurse leaving her assigned unit and 41 residents without licensed nursing coverage, medication administration, or emergency care capability for over two hours during the night shift. According to the facility incident report and interviews, the RN assigned to the 4th floor (Nurse MI) clocked out and left the facility at 4:19 AM while responsible for 41 residents, with only two CNAs remaining on the floor. She did not wait for relief from another licensed nurse, did not provide a proper handoff, and did not notify the CNAs that she was leaving. Prior to leaving, she turned the medication cart and narcotic keys over to the front receptionist, a non-licensed staff member, instead of directly to another licensed nurse as required by facility policy.

The report states that the receptionist, believing the keys should be held by licensed staff, took them to the 3rd floor nurse. The 3rd floor nurse, who already had 48 residents, refused to accept responsibility for the additional 41 residents and did not take the keys, stating it would be unsafe to be responsible for a total of 89 residents. No licensed nurse was present on the 4th floor from approximately 4:19 AM until about 6:30 AM, when the 4th floor unit manager arrived after being informed there had been no nurse on the unit for over two hours. During this period, only the two CNAs provided care, and they reported they were busy with resident care and did not realize the nurse had left until the morning nurse arrived.

As a result of the absence of a licensed nurse, all 6:00 AM medications, assessments, and treatments for the 41 residents on the 4th floor were not administered or performed. Record review showed that one resident (R6) missed scheduled albuterol nebulizer treatments at midnight and 6:00 AM, and another resident (R5) did not receive scheduled suctioning by mouth at 6:00 AM, as well as scheduled PEG tube medications for cancer pain at 2:00 AM and 6:00 AM. A nurse who came on at 7:00 AM confirmed that 6:00 AM medications, vital signs due for medications, and nebulizer treatments were not given, and that she began the 8:00 AM medication pass upon starting her shift. Narcotic reconciliation records for the 4th floor medication carts showed missing or incomplete shift inventory documentation, including lack of a 7:00 AM shift entry for one cart and only a single nurse signature on multiple dates for the other cart, despite policy requiring two nurse signatures each shift. The facility’s resident rights policy and employee handbook, as cited in the report, specify residents’ rights to be free from neglect and require staff not to leave assigned workstations or leave work early without proper approval and handoff.