F0695

J

Failure to Provide Respiratory Monitoring and Care During Power Outage

Des Plaines, Illinois Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide specialized respiratory care and continuous clinical monitoring to ventilator‑dependent residents during a total facility power loss. An area‑wide electrical outage occurred, the facility’s emergency generator failed to activate, and all electrical power to the ventilator unit and other medical devices was lost for approximately 3 hours and 15 minutes. During this time, the facility’s Emergency Operations Plan for loss of electrical power, which required initiation of manual ventilation with Ambu‑bags and continuous assessment of residents by nursing and respiratory staff, was not effectively implemented. All ventilator‑dependent residents were ultimately evacuated to the hospital to maintain their health and safety.

One resident, identified as having chronic respiratory failure and COPD and requiring full mechanical ventilation via tracheostomy, had no documented respiratory assessments, ventilator checks, or clinical monitoring in the EHR from the afternoon prior to the outage through shortly after midnight, encompassing the period of the power failure. The respiratory therapist on duty at the start of the outage did not document any respiratory assessments or monitoring for this resident, and the facility could not provide documentation that manual ventilation was initiated once staff realized the red emergency outlets were nonfunctional. Hospital admission records for this resident showed an elevated lactic acid level, which the report notes can be a marker of tissue hypoxia and metabolic stress during respiratory compromise.

Staff interviews revealed additional gaps in care and monitoring during the outage. There was one respiratory therapist on site for 14 ventilator‑dependent and 6 tracheostomy residents, and the ventilator unit was staffed with two nurses and two aides. One RN reported working a double shift exceeding 14 hours and stated that he did not perform interventions on ventilator patients beyond checking if a resident was breathing or in distress, did not monitor other residents due to limited staffing, and did not document his actions because the computers had no power. Another nurse reported that the outage began around 9:00–9:30 PM, that ventilator power cords were moved to emergency outlets, and that oxygen cylinders were brought to some patients, but there was no documented evidence that the required manual ventilation and continuous respiratory assessments were carried out for the ventilator‑dependent residents during the generator failure.

Removal Plan

• Updated emergency power outage plan.
• Updated staffing plan for emergencies.
• Updated command list for key personnel outlining responsibilities of responsible individuals.
• Created plan to monitor and track maintenance of life maintaining equipment.
• Created QA tool to monitor compliance.
• Reviewed and updated staffing plan.