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Based on medical record review, interviews, review of the Nursing-Patient Task Summary and review of the hospital document titled, "Basic Expectations for Patient Response," nursing staff failed to respond within five minutes (per hospital's basic expectations for Patient Response) to Patient Identifier (PI) #1's request for assistance on 4/19/15.


Findings Include:

PI # 1 was admitted to the hospital on 4/18/15 with a chief complaint of numbness initially across face that gradually developed over the entire body, dizziness and lightheadedness.

Assessment and Plan:
1. Acute severe hypomagnesemia with hypocalcemia; nausea and vomiting for three days. Continue an IV (Intravenous) of normal saline at 125 mL (milliliters) per hour. Recent initiation of Dyazide (medication - a diuretic that causes the body to make more urine, www.webMD.com). Will discontinue Dyazide...

2. Type 2 Diabetes Mellitus. Check blood sugars q.i.d ( 4 times per day)...

8. Altered mental status with intermittent confusion...


A review of the Nursing - Patient Task Summary Form revealed a call (via call bell) was received from PI # 1's room on 4/19/15 at 13:09 regarding PI # 1's request to see a Patient Care Assistant. Staff responded 125 minutes later at 15:14.

A review of the hospital Document, "Basic Expectations for Patient Response," revealed if a patient requests assistance from a Patient Care Assistant the staff should response within five minutes.

During an interview with Employee Identifier (EI) # 3 on 5/6/15 at 13:00, the Chief Nursing Officer (CNO), stated PI #1 reported the concern about the delay in response time on 4/19/15. According to the CNO, the call system known as the Patient Response Center is a centralized system used by the hospital. When a call bell is activated from a patient's room, the request is automatically sent to the Patient Response Center (PRC). PRC staff attempt to ascertain the patient's request/need and relay the request via pager to the appropriate staff. Staff are expected to respond as soon as possible. If a patient makes a request to use the bathroom, staff is expected to respond within five minutes. Special badges, worn by staff, track their entrance, exit and time spent in a patient's room.

During an interview with Employee Identifier # 2 on 5/6/15 at 14:12, the Charge Nurse stated she receives pages that aren't answered or cleared by the Registered Nurse or other staff. In order for the page to be "cleared" staff have to be physically present in the room. According to the Charge Nurse the unit was very busy on 4/19/15 and many of the patients required total care. The Charge Nurse said she received several pages from PI # 1's room and left the desk to check on the patient (PI # 1). PI # 1 wanted her blood sugar checked. According to the Charge Nurse, PI # 1 was alone in the room. There is no documentation in the Patient Progress Note about the Charge Nurse's interaction with PI # 1.

The Nursing-Patient Task Summary dated 4/19/15 revealed the Charge Nurse entered PI # 1's room at 15:14: 125 minutes after PI # 1 used the call bell to request assistance from the Patient Care Assistant.

Patient Progress Note:

4/19/15 at 15:31: Blood sugar 55 (Levels vary depending on when and how much was eaten at the last meal. In general: 80-120 mg/dL before meals or when waking up; 100-140 mg/dL at bedtime, www.webmd.com). Gave patient graham crackers and juice.

During an interview with Employee Identifier (EI) # 1 on 5/6/15 at 14:12, the Registered Nurse (RN) stated she was aware PI # 1 called for assistance. However, she was in a patient room removing an impaction and the Patient Care Assistant was helping her due to the patient's unique medical issues. The RN stated she could not respond to the page received as a result of PI # 1 using the call bell to request assistance from staff.

In summary, staff failed to respond within five minutes per hospital's basic expectation guideline when PI # 1, a diabetic patient receiving insulin, called for assistance using a call bell on 4/19/15 at 13:09. An RN responded 125 minutes after PI # 1's initial request for assistance. PI # 1's blood sugar was 55.

Post complaint actions initiated by the hospital after complaint received from PI # 1 on 4/19/15:

1. Instructed staff to call desk if they receive a page that they cannot immediately answer.

2. Continue to evaluate Patient Response Center / Aionex (name of call system) response times to evaluate for outliers. Nurse Managers to follow-up as required.

3. Review response expectations with Patient Experience Team and discuss ways to improve actual and perceived delays in response.

4. Escalations go to the House Supervisor.