F0684

J

Failure to Respond to Ventilator Alarms and Maintain Vent Circuit Leading to Resident Death

Niles, Illinois Survey Completed on 02-05-2026

Penalty

No penalty information released

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.