The incident occurred at Community Hospital of San Bernardino's skilled nursing facility when Respiratory Therapist 1 helped transport the ventilator-dependent resident to a shower room at 10:30 AM. RT 1 disconnected the resident from their ventilator and attached them to an Ambu bag connected to 10 liters per minute of oxygen for the 30-minute shower.
After returning the resident to their room at 11:00 AM, RT 1 reconnected them to the ventilator and performed a tracheostomy dressing change. But RT 1 failed to take the ventilator out of standby mode.
The resident remained without mechanical ventilation for 3 hours and 4 minutes.
At 1:35 PM during routine rounds, RT 1 found the resident "lying in bed, pale, eyes closed, unresponsive, no pulse or respirations, and the ventilator was on standby mode." RT 1 immediately notified the charge nurse and a code blue was initiated.
Certified Nursing Assistant 1, who helped with the shower, told inspectors she "did not see the ventilator being turned on" after RT 1 reconnected it. CNA 2, who also assisted, said RT 1 "connected Resident 1 back to the ventilator and changed tracheostomy dressing, but CNA 2 does not remember looking at the ventilator."
The facility's biomedical technician confirmed through ventilator data logs that the machine remained on standby mode from 10:35 AM to 1:39 PM. The same technician verified that scheduled preventative maintenance had been performed on the ventilator and "there was nothing wrong with the ventilator."
RT 1 told inspectors he believed he had "resumed ventilation from standby mode" after reconnecting the resident. But the facility's Director of Clinical Patient Services confirmed through the ventilator's electronic records that RT 1 "did not resume ventilation from standby mode."
The resident was transferred to the intensive care unit at 2:18 PM for close observation and treatment. When inspectors observed the resident in the ICU the following day, they were attached to a ventilator with oxygen levels set at 30 percent.
Federal inspectors classified the incident as causing actual harm to the resident. The inspection report states the resident "experienced respiratory arrest (a person has stopped breathing or is breathing so weakly that is not sustainable for life), which led to initiation of code blue and transferred to ICU for closed observation and treatment."
The failure occurred despite multiple staff members being present during the shower and return process. Three staff members — RT 1, CNA 1, and CNA 2 — were involved in transporting the ventilator-dependent resident, yet none verified the ventilator was properly functioning after reconnection.
Ventilator-dependent residents require continuous mechanical breathing support. When the machine is in standby mode, it does not provide the positive pressure ventilation necessary to sustain life for patients who cannot breathe adequately on their own.
The incident highlights the critical importance of verification protocols when reconnecting life-sustaining equipment. While RT 1 performed the technical tasks of disconnection and reconnection correctly, the failure to activate the ventilator from standby mode left the resident without essential breathing support during a vulnerable period.
The resident's condition following the respiratory arrest required intensive care monitoring, demonstrating the serious medical consequences of the equipment failure. The three-hour period without mechanical ventilation represented a significant interruption in the continuous care required for ventilator-dependent patients.
Full Inspection Report
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