Failure to Maintain Functional Suction Equipment on Crash Cart
Penalty
Summary
The facility failed to ensure that an oxygen nut and stem adaptor, commonly referred to as a 'Christmas tree' connector, was readily available and connected to the portable suction machine on the south station crash cart. This deficiency was identified when staff were unable to provide suctioning to a resident during an emergency situation because the necessary plastic connector piece was missing from the suction machine. Multiple staff interviews confirmed that, during the incident, the suction machine could not be used as intended due to the absence of this critical component, and staff were unaware of where to locate a replacement. The incident involved a resident with a history of heart failure and type 2 diabetes mellitus, who was found unresponsive, without a pulse, and not breathing while sitting on the toilet. Staff initiated CPR and attempted to clear the resident's airway, noting the presence of food and secretions in the mouth. Despite efforts to remove the obstruction manually, the inability to use the suction machine due to the missing connector impeded the staff's ability to clear the airway effectively during the emergency. Interviews with various staff members, including CNAs, respiratory therapists, and nursing leadership, revealed that it was the responsibility of the night shift to check and ensure the crash cart was fully stocked and that all equipment, including the suction machine, was operational. The facility's policy required that all critical supplies for basic life support be available and replaced promptly after use. However, the missing connector on the suction machine was not identified or replaced prior to the emergency, resulting in the equipment being nonfunctional when urgently needed.