Generator Failure and Inadequate Emergency Response for Ventilator-Dependent Residents
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a tracheostomy and chronic respiratory failure was found to have their oxygen concentrator and suction machine plugged into a standard wall outlet instead of a generator-powered outlet. Staff confirmed that only red faceplate outlets were connected to the backup generator, but these were already in use for other equipment. The facility's policy directed staff to move equipment after a power outage rather than ensuring critical devices were always connected to emergency power, and documentation of required safety checks was not provided.
The facility did not maintain an operable emergency power system during a prolonged outage, resulting in a complete loss of power. Staff were unable to access electronic medical records, emergency lighting was initially unavailable, and a resident requiring high-flow oxygen was transferred to the hospital due to the inability to provide necessary care. The facility did not follow its emergency procedures to obtain a backup generator, affecting all residents.
A facility's generator failed during a planned power outage, leaving 13 residents who required oxygen concentrators without power for approximately 15 minutes. The generator malfunctioned due to a faulty oil pressure sensor, which was not detected during annual maintenance. This failure put residents at risk of respiratory distress.
The facility experienced a delay in the activation of its emergency power system during a power outage, resulting in a two-minute period without power for emergency exit signs, lighting, and medical equipment. Staff had to manually switch residents requiring oxygen to portable tanks. The facility's policy requires immediate notification of the Administrator and Maintenance Director if the generator fails to activate within 10 seconds.
The facility experienced a complete power outage due to a failure in the temporary generator, which had been in use since 2020. This outage affected medical equipment, elevators, and refrigeration units, and required manual intervention to restore power. Residents on oxygen concentrators were switched to O2 tanks, and staff faced challenges due to non-functional elevators and a lack of standard procedures for power outages. The deficiency was confirmed during an exit conference.
A power outage in an LTC facility left 88 residents without power for over 30 minutes due to a delayed generator start. A resident was unable to use their CPAP machine and had to sleep on a deflated mattress. The delay was caused by a breaker switch not being in the 'ON' position, which was discovered after a significant delay.
Failure to Ensure Critical Respiratory Equipment Connected to Emergency Power
Penalty
Summary
The facility failed to ensure that critical medical equipment for a resident requiring continuous respiratory support was plugged into generator-powered outlets. Specifically, a resident with a history of traumatic brain injury and chronic respiratory failure, who had a tracheostomy and required continuous oxygen, was found to have their oxygen concentrator and suction machine plugged into a standard wall outlet via a power strip, rather than into the generator-supplied (red) outlets. The generator-powered outlets in the room were already in use for other medical equipment, leaving no available emergency outlet for the resident's life-sustaining devices. During interviews and observations, staff, including a respiratory therapist and the maintenance assistant, confirmed that only outlets with red faceplates were connected to the backup generator and should be used for critical equipment during a power outage. The Director of Nursing (DON) initially stated that it was not an issue since there was no current power outage and that equipment would be moved to generator outlets if needed. However, when asked to demonstrate this process, staff realized that moving the equipment would require additional steps, such as obtaining a portable oxygen tank, and that the generator outlets were already at capacity. The facility's policy instructed staff to move equipment to generator-powered outlets after a power outage, rather than requiring proactive connection of critical equipment. The Nursing Home Administrator (NHA) stated that safety checks were performed every shift to ensure life-sustaining equipment was plugged into emergency outlets, but was unaware that the resident's equipment had been found plugged into a standard outlet. Requested documentation of these safety checks was not provided to the surveyor by the time of survey exit.
Failure to Maintain Emergency Power System During Outage
Penalty
Summary
The facility failed to maintain an operable emergency electrical power system, resulting in a complete loss of power for an extended period following an ice storm. The generator, which was supposed to supply power to the entire facility during outages, ceased functioning and was not promptly replaced with a backup generator as outlined in the facility's emergency procedures. During the outage, staff were unable to access electronic medical records due to insufficient battery backup, and the backup computer could not support both the laptop and printer simultaneously. Emergency kits containing flashlights were initially inaccessible, leading staff to use personal phones for lighting until the kits could be reached. One resident who required 10 liters of oxygen was sent to the hospital for the duration of the outage because the facility was unable to provide adequate care without power. Other residents who relied on specialized air mattresses were switched to standard mattresses. Interviews with the NHA, DON, and a regional clinical RN confirmed that the facility did not follow its emergency procedures for obtaining a backup generator and that there were multiple instances where the generator failed to function properly, impacting the care and safety of all 82 residents.
Generator Failure During Power Outage
Penalty
Summary
The facility failed to provide a working generator for 13 residents who required oxygen concentrators during a planned power outage. The generator, which was supposed to supply power during the outage, malfunctioned due to a faulty oil pressure sensor. This malfunction was not detected during the annual maintenance of the generator, leading to a power loss for approximately 15 minutes. During this time, the residents who depended on oxygen concentrators were at risk of being without oxygen, potentially leading to respiratory distress. The issue was identified during an interview with the Administrator, who confirmed the generator's failure during the planned outage. The Maintenance Environmental Services staff also confirmed the generator's malfunction and attributed it to the oil pressure sensor failure. The Director of Nurses acknowledged that all 13 residents required oxygen concentrators, highlighting the critical nature of the generator's failure. The facility's policy on emergency generator testing, dated 9/2017, indicated that generators should be maintained in an operational state, but this was not adhered to, resulting in the deficiency.
Emergency Power System Delay During Outage
Penalty
Summary
The facility failed to ensure that the emergency electrical power system activated within the required 10 seconds during a power outage, affecting all residents. On the day of the incident, a complete power outage occurred at 10:00 AM, and the emergency generator did not become operational until 10:02 AM. During this two-minute interval, there was no electrical power to supply emergency exit signs, lighted means of egress, or any electric-powered medical equipment, such as oxygen concentrators. Nursing staff had to manually switch residents who required oxygen to portable tanks or connect their concentrators to emergency outlets. The facility's Administrator confirmed the power loss and acknowledged that the generator should have activated within 10 seconds. A review of the facility's policy on emergency generator malfunction indicated that the Charge Nurse should contact the Administrator and Maintenance Director if the generator fails to restore power within the specified time. Additionally, the facility's Emergency Generator Monthly Test Log showed that the generator typically activated within 3-5 seconds, indicating a deviation from the norm during the incident.
Emergency Power System Failure
Penalty
Summary
The facility failed to ensure that its emergency and standby power systems were functioning properly, which led to a complete power outage on July 14, 2024. The facility had been relying on a rental generator since March 2, 2020, and during the power failure, the temporary generator did not activate, leaving the facility without power. This outage affected critical systems, including medical equipment, elevators, and refrigeration units. Staff interviews revealed that the maintenance director was notified of the outage and arrived at the facility to find it in darkness, with staff panicking. It took approximately one hour to troubleshoot and manually start the generator, but the chillers remained inactive due to high voltage requirements. Additionally, the circular pumps were bypassed, and alarms were turned off, which contributed to the delay in addressing the issue. The power outage had significant implications for resident care, as those on oxygen concentrators had to be switched to O2 tanks. The lack of power also raised concerns about resident safety, as the elevators were non-functional, preventing the movement of residents if necessary. Staff interviews indicated a lack of standard procedures for handling power outages, and no mock disaster drills had been conducted. The absence of red plugs in resident rooms further complicated the situation, as extension cords had to be used. The deficiency was confirmed during the exit conference on July 18, 2024, highlighting the facility's prolonged reliance on a temporary generator without a permanent solution in place.
Delayed Generator Start Causes Power Outage
Penalty
Summary
The facility failed to ensure that the emergency generator started and transferred power within 10 seconds after a power outage, resulting in a lack of power for over 30 minutes for all 88 residents. On the night of the incident, the generator did not start promptly due to a breaker switch not being in the 'ON' position, which was discovered by the Maintenance Assistant after a delay. This delay in power restoration affected the residents, including one who was unable to use their CPAP machine and had to sleep on a deflated low-air loss mattress, causing discomfort. The Director of Maintenance and the Maintenance Assistant provided conflicting accounts of the generator's usual start time, with the Assistant indicating a delay of 20-30 minutes on the night of the outage. The facility's policy required the generator to operate as designed, but the maintenance records did not indicate that critical equipment like the CPAP machine and mattress were connected to generator-powered outlets. The Director of Maintenance was responsible for maintaining the generator, but the incident revealed a lapse in ensuring the generator's readiness and the staff's ability to manage the situation effectively.
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