F0906

L

Generator Failure and Inadequate Emergency Response for Ventilator-Dependent Residents

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that its emergency generator functioned during a widespread power outage and to document required weekly and monthly testing of the generator. On the evening of 09/20/25, the primary utility power failed, and the facility’s emergency generator did not engage as designed. The Administrator reported arriving to find the building dark, with the Maintenance Director already on-site attempting to troubleshoot the generator and having contacted the generator contractor. The Administrator stated that the root cause, as relayed by the generator service company, was that condensation in the gasoline tank may have caused water and gas to mix, which then burned out the generator wiring that activates the unit. Review of maintenance records revealed no evidence of weekly generator inspections or monthly load-bank testing for the three months preceding the outage.

During the outage, all areas of the facility lost electrical power, including power to mechanical ventilators, tube feeding pumps, air mattresses, mechanical lifts, and other electrically powered equipment. Fourteen ventilator-dependent residents were affected when the emergency generator failed to provide power to life-sustaining devices. The Maintenance Director confirmed that emergency outlets (red plugs) remained without power until a portable generator was obtained and connected at 12:41 AM the following morning. Staff attempted to plug ventilators and other equipment into the red emergency outlets, but nursing staff reported that there was no power to those outlets and that the unit was in total darkness.

Nursing and respiratory staff actions during the outage did not follow the facility’s Emergency Operations Plan. The plan states that if a ventilator battery does not continue operating or power is lost, manual ventilation (Ambu-bagging) must be initiated immediately, and that nursing and respiratory staff will ensure medical equipment is energized via red emergency outlets and will continually or continuously assess residents. One RN reported working a double shift and remaining on duty into the early morning hours, stating that he did not initiate manual ventilation or conduct specialized respiratory monitoring for ventilator patients, explaining that he “didn’t do anything to the ventilator patient, it’s not my thing,” and that he focused primarily on one ventilated resident and did not monitor other residents. Another nurse confirmed that manual ventilation was not performed for any of the 14 ventilator-dependent residents during the outage and that she had to call the respiratory therapist when she noticed the ventilators were dark, after which she brought oxygen cylinders to several patients.

Staff also demonstrated a lack of knowledge regarding backup ventilator batteries. Two nurses working on the ventilator floor stated they did not know where backup batteries for the ventilators were stored in case of power failure. Personnel file review showed that the RN who was on duty during the outage lacked documented competency evaluation for ventilator management or emergency respiratory procedures such as Ambu-bagging. The combination of the generator’s failure to activate, the absence of documented generator testing, the lack of power to emergency outlets, and the failure of nursing and respiratory staff to implement the facility’s emergency procedures for ventilator-dependent residents led to the cited deficiency and was determined to constitute Immediate Jeopardy to resident health and safety.

Removal Plan

• The facility has an emergency policy and procedure system in place on what to do if the facility's electrical system is affected.
• The emergency policy and procedure affecting the facility's electrical system is reviewed upon hire during orientation and educated on annually.