Failure to Ensure Proper Ventilator Alarm Function and Settings for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required mechanical ventilation. For one resident with anoxic brain damage, tracheostomy, and respiratory failure, the secondary ventilator alarm located outside the room was observed to be turned off for approximately 25 minutes after the resident returned from a shower. The respiratory therapist responsible for the resident stated that the alarm was turned off during the shower and was not turned back on in a timely manner upon the resident's return. The resident was cognitively impaired and totally dependent on staff for activities of daily living, including respiratory care. For another resident with chronic respiratory failure, COPD, and dependence on a ventilator, the secondary ventilator alarm outside the room was not present because it was broken and had been sent to maintenance for repair. Additionally, the primary ventilator alarm at the bedside was set to a low volume, making it difficult for both the resident and staff to hear when the room door was closed. The respiratory therapist confirmed that the alarm should have been set to medium or high and acknowledged the increased risk due to the absence of the secondary alarm and the low setting of the primary alarm. The resident had moderate cognitive impairment and required substantial to maximal assistance with daily activities. Interviews with staff revealed a lack of timely communication and follow-up regarding the repair and reinstallation of the ventilator alarm. The maintenance supervisor was not informed about the broken alarm until he discovered it in his office, and the director of nursing confirmed that both primary and secondary ventilator alarms should be operational and set to high volume to ensure prompt care. Facility policies required immediate response to ventilator alarms and corrective action within the scope of practice, but these procedures were not followed in the cases observed.