Failure to Provide Required AMBU Bag at Bedside for Ventilator-Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy and ventilator dependence, who had a history of acute respiratory failure with hypoxia, did not have an Artificial Manual Breathing Unit (AMBU) bag at the bedside as required by facility policy. During an observation, it was noted that the AMBU bag was not present in the resident's immediate vicinity. Multiple staff interviews confirmed that an AMBU bag was supposed to be at the head of the bed for all residents with a tracheostomy and ventilator, and that its absence was unacceptable. Staff searched the room but were unable to locate the required equipment. The facility's policy, dated April 17, 2025, specified that a manual resuscitator device must be placed at the bedside of each resident. Both the respiratory therapist and the respiratory therapy resource confirmed the importance of having the AMBU bag readily available for manual ventilation in case of emergency. The deficiency was identified through observation, staff interviews, and review of the facility's policy and the resident's medical record.