{"id":20,"form_id":"15","user_id":"81","question_id":null,"organization_id":"10","tab_id":null,"question_type":null,"text_answer":"{\"Short_Answer__76\":\"201905316\",\"Date__77\":\"08\\\/15\\\/2019\",\"Multiple_Choice__78\":\"Jill Tilbury\",\"Multiple_Choice__79\":\"Charles Young\",\"Short_Answer__80\":\"Progressive Living Inc\",\"Short_Answer__82\":\"nicole.s@progressivelivinginc.net\",\"Multiple_Choice__84\":\"Medication Error\",\"Multiple_Choice__85\":\"Blue Earth County\",\"Date__86\":\"07\\\/20\\\/2019\",\"Free_Text__87\":\"on 7\\\/20\\\/19 It had been reported to On-call that a scheduled 2 medication had 2 tablets gone missing. Staff reported this to On-call right away in the AM. DCC complained about staff on the Overnight not being awake when he was attempting to wake them up for a PRN. Staff administered an Acetaminophen to DCC at 5:00am. It is suspected that the staff on the overnight were asleep not supervising DCC and after administering the medication DCC reported the staff went back to the couch to sleep after he took his PRN. Staff may have not locked up the office and DCC may have gotten the keys from the key lockbox by breaking into it to get the schedule 2 medication. DCC has in the past requested multiple times from staff stating he has not gotten this medication. DCC has had a problem with medication seeking.\",\"Multiple_Choice__96\":\"1\",\"Short_Answer__91\":\"Staff did not count medications per provider policy\",\"True_or_False__94\":\"Yes\",\"Date__97\":\"09\\\/13\\\/2019\",\"Free_Text__98\":\"\\\"Staff 1 worked a double shift (working at other homes within agency) prior to arriving at 11pm and then came to work the overnight shift at the location of the incident.  Staff 2 stated this was the first shift of the day for them.  The provider\\u2019s shift are from 11p-7am; 7am-3pm; 3pm-11pm.  Both staff were float staff for several homes throughout the agency, however they had worked in this home prior to the event.  Staff 1 worked for the provider for over a year and Staff 2 had worked for the provider since February.  Each of the staff works approximately 40-48 hours per week.  Provider has a policy for a 2:4 staffing ratio at the home and both staff remain awake.  \\r\\n\\r\\nProvider\\u2019s policy is to go into the office and count medications upon arriving for a shift.  While in the office they are to also read the daily log notes on the people supported in the home.  The 11pm staff arrived for their shift, neither staff person had reviewed the notes from the previous shift or counted the medications.  This had been the pattern that staff did not typically check meds and\\\/or notes when they arrived to the home because the norm was the individuals were awake and needed support.  The staff started interacting with the individuals in the home because many of them were awake on this evening and required the staff\\u2019s attention. Individual 1 typically was not awake and in the common area of the home, however they were on this evening.  \\r\\n\\r\\nIndividual 2 (with alone time) from the residence called and stated he needed a ride home.  Staff 1 left to go get individual 2.  Staff 1 did not take the office keys with them when they left the home.  Staff 1 did not know if the office was locked at this time.  \\r\\n\\r\\n\\r\\nWhen both staff arrive Individual 1 was typically in their room and this night the individual was awake more during the night and was talking to Staff 2 about videos games and film animation.  Individual 1 has no alone time.  Individual 1 is very planful, smart, he works at a department store, likes animation or playing videos games, funny, jokester, and typically calm.  \\r\\n\\r\\nAt 5am Individual 1 came to Staff 1 for a PRN and staff was watching YouTube videos.  The office is locked at all times per policy from the provider and staff carry the keys on a lanyard (on their person at all times).  One set of keys per two staff.  If keys are locked inside of the office there is another set in a lockbox (with a key code to get in).  Once in the office, the medications are set up per person in a \\u201cfile cabinet like\\u2019 with another set of keys required to get into the medications.  When staff 1 went into the office for the medications the office and the medications were all locked.  Staff 1 gave individual 1 medications and went back to watching youtube from 5am-6am.  Staff 1 was unable recall if they had fallen asleep.   Staff 1 was very tired due to the length of time they had worked during their shift and the previous two shifts at another home.  \\r\\n\\\"\",\"Free_Text__100\":\"\\\"Staff did not count meds per provider policy was influenced by numerous factors.  The norm is to interact with the awake individuals and on this day there was someone awake which is impacted by staff wanting to support the individual based off of the plan of care created by the team and further influenced by societal norms to engage with others and implementing person centered culture mandated by DHS and CMS.  An additional factor was Individual 2 being in the community and needed transportation home. Staff 1 left the home to pick up Individual 2, thus leaving staff 2 alone with an awake Individual 1 who requires a 24-plan of care supported by norms to interact with others and person centered practices.  One element was there was no staff overlap upon both staff arriving to the home which resulted in staff prioritizing interaction with the individuals over counting medications.  The set wages and benefits which was indicative of the care plan therefore influenced by norms to interact with others and person centered practices.   \\r\\n\\r\\nThe final factor was both staff thought Individual 1 had no history of medication seeking supported by their staff not knowing the individual plan for medications due to being trained in several homes with several individuals\\u2019 plans to follow and also being fatigued because the staff had to work overtime prior to this shift.  The agency being shorted staffed is complicated to the set wages and benefits, low unemployment, thus constraining the college employees (seasonal) and this is byproduct of DWRS which was put in place by the legislature.  Contributing factors that further supported the provider\\u2019s policy for the work of the direct care staff 1 and 2 was the nurse\\u2019s license in providing some position to the policy.  Overall the nurse\\u2019s license is regulated by legislation and statute.   \\\"\"}","mcq_answer":null,"other_answer":"0","status":"1","created_by":"81","updated_by":81,"created_at":"4\/23\/2021 10:52:49 am","updated_at":"4\/23\/2021 11:17:38 am","deleted_at":null,"report_name":"JT_Progressive Living-BEC-2019-08"}