Failure to Ensure Proper Ventilator Alarm Monitoring and Oxygen Administration
Penalty
Summary
The facility failed to ensure that external ventilator alarms were properly monitored and functioning for two residents who required ventilator support. In one instance, a resident using an AVAPS ventilator experienced a disconnection of her oxygen hose, which triggered the internal alarm in her room. The call light was tied to the side of the bed and not within the resident's reach, delaying her ability to summon help. A CNA eventually responded, reattached the oxygen hose, and the alarm ceased. However, the external alarm outside the room was found to be turned off, and it was not reactivated until a respiratory therapist entered the room later. The resident and staff confirmed that the external alarm was not sounding during the incident, and the alarm log verified a patient circuit disconnect alarm lasting approximately 11 minutes. Another resident, dependent on an ACVC ventilator, was observed with the external ventilator alarm turned off during a routine walk-through. The respiratory therapist confirmed that the alarm should not have been off. Facility policy required that staff be trained and competent in the use of mechanical ventilation, including responding to alarms, but the policy for noninvasive ventilation did not specify alarm monitoring procedures. The failure to ensure alarms were active and monitored had the potential to affect additional residents using ventilators in the facility. Additionally, the facility failed to follow physician orders regarding oxygen administration for a resident who required oxygen via nasal cannula at three liters per minute during all medication administrations and meals due to diminished lung capacity and aspiration risk. Video evidence showed the resident eating lunch without her nasal cannula on, and the respiratory therapist had not transitioned her to the nasal cannula after removing the AVAPS mask. Interviews with staff confirmed that the resident was supposed to be on nasal cannula during meals and medication administration, but this was not consistently implemented.