Failure to Resume Ventilator Support After Shower Leads to Resident Respiratory Arrest
Penalty
Summary
A deficiency occurred when a ventilator-dependent resident was not safely reconnected to their ventilator following a shower. The resident, who had a history of sepsis, anoxic brain injury, encephalopathy, and chronic respiratory failure, was transferred from the ventilator to an Ambu bag for the duration of the shower. Upon returning to the room, the Respiratory Therapist (RT) reconnected the resident to the ventilator but failed to resume ventilation from standby mode, leaving the ventilator inactive. Multiple staff members, including Certified Nursing Assistants (CNAs) and a Registered Nurse (RN), were involved in the resident's care during this period. The RN, who was overseeing 28 residents including 15 on ventilators, did not check the ventilator or its settings after the resident returned from the shower. The CNAs assisted with the shower and observed the reconnection process but did not verify that the ventilator was turned on. The RT stated that they resumed ventilation from standby mode, but ventilator logs and a review by the Bio Med Technician confirmed that the ventilator remained on standby for over three hours. As a result of the ventilator not being activated, the resident was found unresponsive, without a pulse or respirations, and a code blue was initiated. The resident required emergency intervention and was subsequently transferred to the ICU for close observation and treatment. Facility records and interviews confirmed that the ventilator was functioning properly but was not taken out of standby mode after the shower, directly leading to the resident's respiratory arrest.