F0658

E

Unattended Unit Leads to Missed Early‑Morning Medications, Treatments, and Documentation Failures

Flint, Michigan Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure continuity of care and timely administration of medications and treatments for all 41 residents on the 4th floor when the only licensed nurse assigned to that unit left the building for over two hours without relief. According to the facility incident report and interviews, the RN assigned to the 4th floor clocked out and left at approximately 4:19 AM, leaving 41 residents with only two CNAs and no licensed nurse to assess, administer medications, or respond to medical needs and emergencies between 4:19 AM and about 6:30 AM. The nurse left the medication keys with the front receptionist instead of a licensed nurse, and the receptionist then attempted to give the keys to the 3rd floor nurse, who refused to assume responsibility for an additional 41 residents. The DON, who was the on‑call manager, did not respond to calls or texts at the time because she was asleep, and no other nurse manager or on‑call nurse responded, leaving the 4th floor without licensed nursing coverage during that period.

Record review showed that during this time frame, multiple scheduled medications, PRN medications, and treatments due during the night and early morning were not administered or documented as given for numerous residents with significant medical conditions. One resident with pain, vascular angioplasty, malignant neoplasm of bone, and a pressure ulcer did not receive scheduled 6:00 AM medications including Lasix and omeprazole, and PRN hydrocodone for pain was not assessed or administered. Another resident with type 2 DM, COPD, and chronic pain did not receive scheduled famotidine and hydralazine doses, and PRN pain medication was not assessed. A resident with COPD, heart failure, and acute kidney failure did not receive scheduled ipratropium‑albuterol breathing treatments at midnight and 6:00 AM, and pain assessments and PRN pain medications were not documented. A resident with malignant neoplasm of the mandible, PEG tube, and need for routine suctioning did not receive scheduled suctioning, levothyroxine, gabapentin, ondansetron, or scheduled PEG‑tube pain medications during the night and early morning.

Additional residents with acute respiratory failure, quadriplegia with tracheostomy and gastrostomy, chronic pain, diabetes, CKD stage 5, hypertension, heart failure, and other serious diagnoses also missed ordered treatments and medications. One resident missed albuterol nebulizer treatments at midnight and 6:00 AM and was later sent to the hospital for a change in condition on that date. Another resident did not receive scheduled lidocaine patches for knee pain. A quadriplegic resident with trach and PEG did not receive scheduled baclofen, nutritional supplement (Med Pass), tizanidine, or documented turning and repositioning every two hours. A resident with diabetes and CKD stage 5 did not receive scheduled insulin glargine at 6:00 AM. Other residents did not receive scheduled furosemide, omeprazole, sertraline, Ventolin inhaler doses, ipratropium‑albuterol breathing treatments, or ordered blood pressure checks and antihypertensive medication at 6:00 AM. Late entries by the DON were made approximately two weeks later, documenting generic assessments such as “no signs and symptoms of pain or discomfort noted,” without contemporaneous documentation from the date of the incident.

The investigation also identified failures in narcotic control documentation and shift‑to‑shift reconciliation. Review of the controlled substance shift inventory for the 4th floor medication carts showed missing entries and lack of required two‑nurse signatures for narcotic counts on the relevant date and surrounding dates. The Unit Manager confirmed that policy requires two nurse signatures each shift to balance narcotics and that if it is not written, it did not happen. The facility’s charting and documentation policy requires that all services provided, progress toward care plan goals, and any changes in condition be documented in the EMR to facilitate communication among the interdisciplinary team, yet multiple services, assessments, and medication administrations during the period without a licensed nurse were not documented as provided. The administrator did not provide requested policies related to medication administration, scheduling, narcotic counts, change‑of‑shift duties, and missed medications at the time of surveyor request, and the list of residents sent to the hospital did not include the resident who was documented as having been sent out for a change in condition on the date in question.