- Date
- 10/23/2015
- Report number
- OR0001019903
- Type
- Licensing Violation
- Level
- 1 - No harm or potential for minor harm
- Allegation
- Failed to provide appropriate staffing
- Result
- Substantiated
- Findings
- Failure to timely respond to emergency call buttons4110540070(1)Resident 1 on October 28, 2015 shared another incident that occurred on September 30, 2015 where he/she had a reaction to what he/she believed was too much insulin in his/her body which caused his/her blood sugar to drop. Resident 1 indicated that he/she pulled the emergency chord and staff responded promptly. Responding staff indicated he/she would summon a medical staff and left. Resident 1 stated that he/she pulled chord again after a 45 minute wait and a different staff member promptly responded indicating the same. Resident 1, feeling ill, fell asleep and awoke two and one half hours later to discover that medical staff still had not responded. Resident 1 then indicated he/she pulled emergency chord again and this time Staff 10 responded and determined Resident 1 ' s blood sugar was too low and gave him/her two glasses of orange juice and a sandwich to bring his/her blood sugar up. CS found a partial reference to the incident in Resident 1 ' s September 30, 2015 MAR where it only indicates that " (r)esident 1 asked for his/her capillary blood glucose (CBG) in his/her room because they were not feeling well. Resident 1 ' s CBG level was 62. Gave 1c. OJ & retested 15 min. later. CBG was 73. Gave another OJ which (he/she) drank w/ a sandwich. CBG went up to 78 in 15 min. Put on Alert. RN texted. " There was no reference anywhere to how long Resident 1 was waiting for medical staff assistance.Additionally, CS could not locate any reference to this incident in Resident 1 ' s Progress Notes nor does Resident 1 recall which staff responded.Staff 13 interviewed October 23, 2015 November 10, 2015 could not explain why there seemed to be communication problems between caregiving staff responding to emergency chords and medical staff who would know how to deal with Resident 1 ' s issue; however, they did point to many unscheduled needs occurring at the same time. Staff 1 and Staff 2 were both also asked to provide a resident to acuity formula to determine if facility has adequate staffing levels. Staff 2 indicated that the facility should have its proprietary program up to determine acuitytostaffing levels in February 2016.Resident 1 interviewed on October 23, 2015 indicated that emergency chord response times vary but usually is slow requiring more than 1015 minutes. Resident 3 also interviewed on October 23, 2015 indicated he/she does not pull emergency chord much but when he/she does, staff responds in short time.Resident 7 interviewed on October 29, 2015 indicated he/she does not pull emergency chord regularly but is satisfied with staff response time.Resident 8 interviewed on January 13, 2016 indicated he/she is satisfied with staff response times to pulled emergency chords.Resident 9 also interviewed on January 13, 2016 indicated he/she is satisfied with staff response times whenever he/she pulls emergency chords.