Failure to Maintain Functional Suction Equipment
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, specifically regarding one of four suction machines reviewed. On the date in question, staff attempted to use the suction machine located in a resident's room to clear oral secretions, but the machine was not functioning. As a result, staff had to retrieve a suction machine from the crash cart, causing a delay in care. Multiple staff interviews confirmed that the in-room suction machine was nonfunctional at the time it was needed. The resident involved had significant medical needs, including Alzheimer's disease, dysphagia, congestive heart failure, dementia, Parkinson's disease, COPD, a gastrostomy tube, a pacemaker, and was dependent on staff for all activities of daily living. The resident was on hospice care and had a suction machine in the room as part of a hospice bundle, although there was no current physician order for suctioning at the time of the incident. The care plan and physician orders did not mention oral suctioning as an intervention or requirement for the resident. Interviews with facility leadership revealed there was no policy in place for checking or maintaining the functionality of suction machines. The Director of Nursing and Administrator both stated that whoever placed the suction machine in the room was responsible for checking it, but there was no formal process or documentation for routine equipment checks. Review of facility policies indicated a requirement for a preventive maintenance program for essential equipment, but this was not implemented for suction machines, leading to the deficiency.