Failure to Respond to Ventilator Alarms and Maintain Vent Circuit Leading to Resident Death
Summary
The deficiency involves the facility’s failure to provide necessary respiratory care and monitoring to a ventilator‑dependent resident by not adequately assessing and responding to ventilator alarms and not ensuring the ventilator circuit and closed suction system were intact and functioning. The resident was an older adult female with encephalopathy, quadriplegia, COPD, vascular dementia, chronic respiratory failure, and complete dependence on mechanical ventilation via tracheostomy. Her MDS documented severely impaired cognitive skills and short‑ and long‑term memory problems. Physician orders specified continuous ventilator support (assist‑control mode, rate 18, tidal volume 400 ml, PEEP 5, FiO2 28% with 2 L/min O2), and care plans directed staff to monitor for signs and symptoms of hypoxia and acute respiratory insufficiency. During the night in question, progress notes show that at approximately 1:45 AM the ventilator alarms were intermittently sounding. The RN responded by entering the room, performing oral suctioning for copious thin secretions, and tracheal suctioning once for a moderate amount of blood‑tinged thin secretions. Vital signs were checked and documented, the G‑tube dressing was changed, and the nurse recorded that the resident was in no distress and that the ventilator was no longer alarming. The nurse later stated in interview that after this suctioning, everything was still connected, the resident’s oxygen saturation was acceptable, and the ventilator stopped alarming. She reported not hearing any further alarms prior to the later emergency. However, review of the ventilator’s VOCSN alarm logs showed multiple high inspiratory pressure and low minute volume alarms between approximately 2:38 AM and 2:39 AM, and low inspiratory pressure and low minute volume alarms between approximately 3:03 AM and 3:04 AM. These alarms alternated between triggered and resolved, indicating on‑and‑off alarm activity. There was no documentation in the resident’s progress notes that nursing or respiratory staff assessed the resident or evaluated the ventilator in response to these alarms. The lead RT and other clinical leaders stated that such alarms require immediate or prompt physical assessment of the resident and ventilator circuit, and that staff are mandated to answer all alarms. At approximately 3:55–4:15 AM, the RT entered the room during rounds and found the resident unresponsive, pale, with no breathing and no vital signs, and disconnected from the ventilator. The RT reported that there was no ventilator alarm sounding at that time and that the ventilator tubing was disconnected and close to the tracheostomy. The RN, called to the room, also found the resident pale, not moving, with no chest rise, and assisted in initiating CPR and calling a code blue and EMS. The ambulance crew documented that staff reported the resident was last seen normal around 2:00 AM and was later found in cardiac arrest with the ventilator disconnected and no alarms sounding. Hospital records documented that the resident arrived in cardiac arrest with absent heart sounds, no palpable carotid pulse, fixed and dilated pupils, and no purposeful response, and she was pronounced dead after resuscitation efforts. The surveyors concluded that the facility failed to assess and respond to ventilator alarms and failed to ensure the ventilator circuit and closed suction system were intact and functioning, resulting in the resident being found unresponsive and disconnected from the ventilator and expiring, and this failure constituted Immediate Jeopardy.
Removal Plan
- Initiate high quality CPR, call a code blue, call EMS, continue CPR until EMS arrives, and transfer the resident to the hospital.
- Check all ventilator-dependent residents for proper connection and alarm function.
- Identify other potentially affected residents, including residents with an open airway and residents utilizing a ventilator.
- Check all ventilator-dependent residents for proper connection and alarm function.
- Check all ventilators to ensure all required maintenance is performed.
- Have the assigned respiratory therapist check all ventilator-dependent residents for proper connection and alarm function every 2 hours and as needed, and document these checks once per shift.
- Conduct staff education by the ADON, lead respiratory therapist, Regional Nurse Consultant, and shift supervisor.
- Provide education to all staff assigned to the respiratory unit, including PRN staff.
- Implement a monitoring process in which the respiratory therapist randomly audits ventilator residents to ensure ventilator settings, connections, and alarm functionality are assessed after care activities that could disrupt the ventilator circuit.
- Implement observation audits of ventilator-dependent residents for secure connections.
- Have the Director of Nursing or designee conduct direct observation in the respiratory unit to ensure prompt response to alarms on random shifts.
- Have the Director of Nursing or designee conduct direct observation of staff to ensure residents with an open airway are repositioned appropriately and carefully to prevent interruption of respiratory tubing.
- Conduct audits for all residents with an open airway, then continue audits weekly.
- Present audit results to the QAPI committee for recommendations of further auditing and actions as appropriate.
- Complete a code blue debrief and have the action plan discussed and approved by the Ad-Hoc committee.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An LPN administered only one tablet of methotrexate instead of the ordered six-tablet dose for a resident with RA. The facility also failed to maintain ordered midline IV care for another resident receiving IV abx, with observations showing a soiled dressing, site discoloration, and later no midline or IV pump present despite orders for ongoing site monitoring, dressing changes, and line removal after tx completion.
A resident with dementia and COPD had an order for continuous O2 via NC, with SpO2 to be maintained between 88% and 92% and not exceed 92%. The record showed SpO2 readings below 88% on room air and multiple readings above 92% while on supplemental O2, with no nursing interventions documented; the DON stated the resident’s SpO2 should have been better monitored and the physician’s O2 order more closely followed.
A resident with a stage 4 pressure injury and sepsis had ongoing loose stools, but the MAR showed no documented PRN loperamide use and the record showed no provider notification despite repeated large loose stools. The same resident was also receiving daily anticoagulant injections and was observed with dark red urine in an indwelling catheter, yet there was no documented bleeding/bruising monitoring, no progress note about the blood in the urine, and no alert charting.
A resident with chronic GI symptoms, malnutrition, diabetes, depression, and PTSD had persistent watery diarrhea, abdominal pain, and nausea, but the facility did not adequately track stool testing, confirm lab results, or complete the ordered GI referral. The resident reported frequent diarrhea, fatigue, reduced intake, and soreness, while staff documentation showed conflicting entries about specimen refusal versus sleeping, and the lab later had no record of the specimen that was charted as sent. The record also lacked evidence that the GI specialist appointment was scheduled or completed, and a separate resident’s ordered ECHO for pericardial effusion was not documented as scheduled or completed.
A resident with a growing facial lesion had a dermatology consult delayed for about 3 months. The resident’s chart included provider orders for dermatology follow-up, but the appointment remained pending while the lesion increased in size. Notes from the NP and unit manager documented ongoing waiting for the consult, and the DON stated the health plan should have scheduled it and that consults need to be scheduled in a timely manner.
A resident with HTN and HF had an order for metoprolol succinate to be held if the pulse was below 55 bpm, but MAR and pulse record review showed missing pulse documentation on multiple occasions, pulse checks done after the med was given, and doses administered when the pulse was less than 55 bpm. Staff stated the pulse should have been checked before administration, and the DNS confirmed the expectation was to follow the order and hold the med when indicated.
Medication Dose Error and Midline IV Care Failure
Penalty
Summary
The facility failed to administer the correct dosage of Methotrexate Sodium for a resident with rheumatoid arthritis. During medication administration, an LPN poured only one 2.5 mg tablet into the medication cup and then administered the medications, even though the physician order required six tablets by mouth every Wednesday for a total dose of 15 mg. The LPN later stated that she should have given six tablets and not one, and the DON stated that the nurse reported the error to her and was instructed to call the provider and notify the resident. The facility policy stated that medications are to be administered in accordance with prescriber orders. The facility also failed to provide IV device care as ordered for a resident receiving midline therapy and IV antibiotics. Observation showed the resident’s midline dressing dated 5/30/2026 with visible purple discoloration at the insertion site and dry blood under the clear dressing, while an empty antibiotic bag remained in the room. On a later observation, the midline and dressing were no longer present, and the IV pump was also absent. The resident’s orders included weekly dressing changes, every-shift site monitoring, and removal of the midline after treatment was complete. The Medical Director stated that the line is to be removed immediately after the last antibiotic dose, and the DON stated that after a verbal order is obtained it is to be entered into PCC by the end of the shift.
Failure to Follow Oxygen Orders for Resident with COPD
Penalty
Summary
The facility failed to ensure physician orders were followed for Resident #11, who was admitted with multiple diagnoses including dementia and COPD. On 6/8/26, the resident had an order for oxygen via nasal cannula continuously and twice daily for COPD, with oxygen titrated to maintain SpO2 between 88% and 92% and not to exceed 92%. The resident’s medical record showed SpO2 readings below 88% on 5/23/26 at 4:27 PM and 5/16/26 at 10:20 AM while on room air, with no interventions documented. The record also showed multiple SpO2 readings above the ordered range while the resident was on supplemental oxygen, including readings of 95% to 98% on several dates, without any nursing intervention documented. Nursing progress notes likewise documented SpO2 of 97% and 98% on 2 L NC without documented intervention. On 6/9/26, the DON stated the resident’s SpO2 should have been better monitored and the physician’s oxygen order more closely followed by staff and was not.
Failure to Monitor Loose Stools and Bleeding During Anticoagulant Therapy
Penalty
Summary
The facility failed to provide treatment and care according to orders, resident preferences, and goals for Resident 81, who was admitted with a stage 4 pressure injury to the bottom and sepsis and was able to make needs known. For bowel management, the resident reported loose stools for a couple of weeks and later stated they had been having diarrhea with abdominal discomfort for 3 days, so loperamide was started as needed. The bowel monitor documented repeated loose stools over several days, including two loose stools on 06/04/2026, three large loose stools on 06/05/2026, and two large loose stools on 06/06/2026 through 06/08/2026. The resident stated staff had not given any medication for the loose stools, the June 2026 MAR showed no documented doses of loperamide, and the record showed no documentation that the provider was notified of the three large loose stools. Staff interviews indicated that frequent loose stools should have been reported to the provider, PRN medication given, and the resident placed on alert charting, but this did not occur. For anticoagulant therapy, Resident 81 was receiving daily anticoagulant injections starting 05/21/2026. During observation, the resident was lying in bed with an indwelling urinary catheter and dark red urine was noted in the tube and bag; the resident stated, "It's never been like that. It's scary." The EHR showed no monitoring for bleeding and bruising related to anticoagulant therapy, and the progress notes contained no documentation about the blood in the urine or alert charting. Staff interviews confirmed the resident had blood in the catheter for a couple of days and that monitoring for bleeding should have been in place, but it was not.
Failure to Follow Up on GI Symptoms, Stool Testing, Specialty Referral, and Diagnostic Order
Penalty
Summary
The facility failed to assess, monitor, follow up, and implement physician-ordered care for a resident with ongoing gastrointestinal symptoms, and failed to develop a care plan addressing persistent diarrhea. The resident was cognitively intact, had diagnoses including diabetes mellitus, protein-calorie malnutrition, depression, and PTSD, and was documented as continent, independent with toileting and transfers, and using a wheelchair. The resident’s care plan addressed GI issues such as peptic ulcer disease, pancreatitis, and chronic nausea, but it did not include a problem, goals, or interventions for ongoing diarrhea, abdominal pain, stool testing, infectious GI illness, or management of frequent stools. The resident’s provider documented worsening diarrhea, abdominal pain, and nausea, and ordered stool testing for enteric pathogens and C. difficile, along with a GI specialist follow-up. Facility records showed repeated documentation of stool collection attempts, including entries that the resident refused or was sleeping, while the resident stated she never refused and that staff often asked when she could not provide a sample or was asleep. A stool specimen was documented as collected and faxed to the lab as STAT, but the medical record lacked laboratory results for that specimen, and later review with the lab found no record that the specimen had been received. The resident continued to report frequent watery diarrhea, abdominal pain, nausea, fatigue, reduced intake, and soreness from repeated bowel movements and wiping. The record also showed that the ordered GI specialist appointment was not documented as scheduled or completed. Staff interviews identified that the HUC was responsible for scheduling follow-up appointments, while nursing staff were expected to enter orders and follow up on pending testing. The DON stated staff should have followed up on pending stool testing, maintained infection control precautions while awaiting results, and notified the provider if the resident refused specimen collection. The resident was later found to have C. difficile detected on stool testing, and the record showed delayed identification and treatment after weeks of unresolved symptoms. In a separate deficiency, the facility failed to ensure a physician’s order was implemented for another resident with end stage renal disease, pericardial effusion, atrial flutter, chronic heart failure, and dialysis dependence. The physician ordered that an echocardiogram be scheduled for the resident by a specified timeframe, but the electronic record lacked documentation that the ECHO had been scheduled, implemented, or completed. The DON and Administrator stated that physician orders were to be entered and verified, and that medical records staff scheduled appointments and nurse managers oversaw implementation, but the order was not completed.
Delayed Dermatology Appointment for Facial Lesion
Penalty
Summary
The facility failed to ensure a dermatology appointment was scheduled for a resident with a facial skin growth, resulting in a 3-month delay in evaluation. Resident #97 had a raised red growth on the left side of the chin/jaw area, with part of the growth hanging from the chin and tangled with the resident’s long hair. During an interview, the resident stated that the nurse practitioner wanted it removed and that it was benign, and later stated that it was growing and needed to be seen by a dermatologist. Record review showed provider orders dated 2/16/2026 and 3/6/2026 for follow-up with dermatology for the lesion on the left jaw/facial lesion, with the health plan to schedule the appointment. Notes from the nurse practitioner and unit manager documented that the resident had been waiting on dermatology, that the lesion had increased in size over the past month, and that the appointment was still pending. The DON stated the health care plan should have scheduled the dermatology consult and that consults need to be scheduled in a timely manner, and also stated there was no policy for scheduling appointments.
Failure to Follow Hold Parameters for Metoprolol
Penalty
Summary
The facility failed to follow physician orders for a resident admitted with hypertension and heart failure who had an order for metoprolol succinate to be held if the pulse was less than 55 bpm. Review of the MAR and pulse records showed no pulse documentation on multiple dates in May and June 2026, and on several dates the resident’s pulse was taken after the medication had already been administered. The records also showed that metoprolol succinate was administered on several dates when the resident’s pulse was less than 55 bpm. During interviews, staff stated the pulse should have been checked before giving the medication, and the DNS stated the MAR was not triggering for the pulse to be taken prior to administration, while also confirming the expectation was to follow the physician order and hold the medication if the pulse was below 55 bpm.
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