On 10/9/2012, five staff members took ten residents to a casino for gambling.
One female resident who required an oxygen tank to deal with chronic respiratory issues went along. Her oxygen tank began to run low and none of the staff members knew how to attach the flow regulator to her new tank.
The resident had to be rushed to the hospital after turning blue, passing out and shaking as though she was having a seizure. She was given emergency resuscitation and treated for hypoxia and respiratory distress.
The five staff members who went on the outing were the administrator, three people from activities, and a janitor. No nursing staff made the trip.