The falsified documentation at Notting Hill of West Bloomfield delayed surgery for a resident who needed their biliary drainage tube replaced. The tube, which drains bile from the gallbladder, had slipped outside the resident's body and the internal tract had closed, making the scheduled replacement impossible.
R704's family discovered the problem during an October 11 visit when they observed drainage from the biliary tube area that had grossly soiled the resident's linens and clothing. They had to find a nurse, who reinforced the area with gauze but never assessed underneath the dressing.
Four days later, R704 arrived at the hospital for a scheduled tube exchange. The physician found the drain was no longer placed internally but was outside the body. The internal tract had closed, and based on the closure, the physician estimated the tube had been dislodged for at least three days.
The surgery had to be rescheduled. R704 would now require an abdominal CT scan with contrast dye before the biliary tube could be replaced.
Federal inspectors reviewing the case found a pattern of missing documentation. The facility's treatment orders required staff to drain the biliary tube every shift and document the amount every shift. But nursing staff failed to document their assessment of the drain every shift from October 1 through October 15, except for October 5.
The documentation gaps should have been a red flag. On October 12, 13, and 14, there was zero output recorded from the drain. For a biliary drainage tube, zero output is abnormal and should have prompted assessment.
Yet on October 15, the day shift nurse documented 60 milliliters of drainage from the tube.
The director of nursing reviewed the October treatment records during the federal inspection and acknowledged the obvious problem. How could there be 60 milliliters of drainage on October 15 from a tube that was not in place?
The director had already confronted the nurse about this documentation. When questioned about recording drainage from a dislodged tube, the nurse became upset, told the director they did not have to deal with this, and quit.
The director acknowledged to federal inspectors that the nurse had falsified their documentation, calling it a concern.
R704 had been a long-term resident at the facility since June 2019 and was readmitted in 2025. The resident had end-stage renal disease and received hemodialysis three times a week. R704 also had a cholecystostomy tube related to gallbladder disease and had severely impaired cognition according to assessments from October 29.
The interventional radiologist's consultation notes from October 15 were stark. The tube was dislodged and the tract was closed. They were unable to replace the tube at that time. The previous exchange had shown the cystic duct was open, but now an abdominal CT scan with contrast would be needed in 10 to 14 days before attempting replacement.
The family filed a complaint with the state on October 31, alleging the facility failed to provide care for the cholecystostomy biliary drain consistent with professional standards and physician orders.
Federal inspectors found the facility failed to provide appropriate treatment and care according to orders for R704, resulting in a delay of surgical intervention to exchange the biliary catheter. The falsified documentation masked the tube dislodgement that should have been identified through proper monitoring.
The case illustrates how documentation failures can compound into medical harm. Had nursing staff properly assessed and documented the drain's output daily as ordered, the dislodgement would have been identified when output dropped to zero. Instead, falsified records suggested the tube was functioning normally even as it lay outside the resident's body.
R704's family had to discover the soiled linens and drainage themselves during their visit. By then, the internal tract had already closed, turning what should have been a routine tube exchange into a more complex procedure requiring additional imaging and surgery.
The nurse who falsified the October 15 documentation had documented 60 milliliters of drainage from a tube that the physician determined had been dislodged for at least three days. When confronted about this impossibility, the nurse chose to quit rather than explain the false entry.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Notting Hill of West Bloomfield from 2025-11-25 including all violations, facility responses, and corrective action plans.
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