Failure to Ensure Critical Respiratory Equipment Connected to Emergency Power
Penalty
Summary
The facility failed to ensure that critical medical equipment for a resident requiring continuous respiratory support was plugged into generator-powered outlets. Specifically, a resident with a history of traumatic brain injury and chronic respiratory failure, who had a tracheostomy and required continuous oxygen, was found to have their oxygen concentrator and suction machine plugged into a standard wall outlet via a power strip, rather than into the generator-supplied (red) outlets. The generator-powered outlets in the room were already in use for other medical equipment, leaving no available emergency outlet for the resident's life-sustaining devices. During interviews and observations, staff, including a respiratory therapist and the maintenance assistant, confirmed that only outlets with red faceplates were connected to the backup generator and should be used for critical equipment during a power outage. The Director of Nursing (DON) initially stated that it was not an issue since there was no current power outage and that equipment would be moved to generator outlets if needed. However, when asked to demonstrate this process, staff realized that moving the equipment would require additional steps, such as obtaining a portable oxygen tank, and that the generator outlets were already at capacity. The facility's policy instructed staff to move equipment to generator-powered outlets after a power outage, rather than requiring proactive connection of critical equipment. The Nursing Home Administrator (NHA) stated that safety checks were performed every shift to ensure life-sustaining equipment was plugged into emergency outlets, but was unaware that the resident's equipment had been found plugged into a standard outlet. Requested documentation of these safety checks was not provided to the surveyor by the time of survey exit.