F0600

E

Failure to Assign Nurse Coverage Resulting in Widespread Missed Medications and Treatments

West Bloomfield, Michigan Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from neglect by not ensuring that a nurse was assigned to a block of rooms (125–147, Orchard Lake hallway) during a day shift, resulting in missed medications and treatments for multiple residents. A family member reported that one resident did not receive any day-shift medications until approximately 9:00 p.m., and stated that a nurse told them no nurse was assigned to that hallway and that other nurses could not assume responsibility without risking their licenses due to high resident loads. Review of the medical record for this resident, who had been admitted with diagnoses including congestive heart failure and atrial fibrillation and required assistance with most activities of daily living per the MDS, showed approximately 16 missed doses of medications/supplements and three missed urostomy treatment opportunities on that day.

Further review of the MARs and TARs for 17 additional residents on the same unit revealed numerous missed medications and treatments during the same day shift. The missed items included, for example, six medications for one resident; 10 medications for another; six medications and eight treatments for another; and up to 18 medications and one treatment for another resident. Additional residents had between three and 17 missed medications each, with several also missing one to four treatments. Certified nursing assistants assigned to the Orchard Lake rooms confirmed that there was no nurse assigned to those rooms during the day shift and reported that, while a nurse from another hallway occasionally came over, they believed residents did not receive medications and that many residents were in pain because they were changed without pain medications.

Review of the facility’s nurse staffing assignment for the day in question showed no nurse scheduled to work the first floor, which had a census of 38 residents, while CNAs were assigned to the Orchard Lake rooms. The DON stated they were unaware that the hallway had no assigned nurse and explained that with a census of 86, three nurses should have divided the building, with one nurse covering a split assignment between floors. The DON indicated there may have been a miscommunication regarding nursing assignments and reported that a missed medication report for that day generated 15 pages of residents with missed medications. A nurse interviewed by phone described poor staffing, noted that usually four nurses were scheduled (two per floor), and acknowledged that on a few occasions only three nurses were scheduled, stating they had informed the facility they could not safely split the building in that manner. The facility’s Abuse Prohibition Policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress and included alleged violations where the facility demonstrates indifference or disregard for resident care, comfort, or safety resulting in such outcomes.