Overdue Preventative Maintenance on Ventilators
Penalty
Summary
The facility failed to perform timely preventative maintenance on ventilators used by two residents in the Subacute Unit. During an observation, it was noted that the maintenance stickers on both ventilators indicated that their scheduled service dates had already passed—one was due for maintenance in June 2023 and the other in September 2024. Both the Assistant Director of Nursing (ADON) and the respiratory therapist acknowledged that the required maintenance was overdue. The residents involved were clinically compromised and dependent on ventilators for breathing support. Interviews with the ADON, two respiratory therapists, and the administrator revealed that the facility's policy required routinely scheduled maintenance of equipment according to manufacturer guidelines. However, all staff interviewed confirmed that this policy was not being followed. The process described involved respiratory therapists notifying the ADON or Director of Nursing (DON) when maintenance was due, after which the ADON or DON would contact an outside company to perform the service. Despite this process, the required maintenance was not completed as scheduled.