Community Hospital Of San Bernardino Dp Snf

During an interview on [DATE], at 1:45 PM, with Certified Nursing Assistant (CNA 1), CNA 1 stated that she took Resident 1 to shower room with CNA 2 and RT 1 on [DATE], at 10:30 AM. CNA 1 saw RT 1 disconnected Resident 1 from ventilator and attached it to Ambu bag (a device used to provide positive pressure ventilation to patients who are not breathing or have difficulty breathing).

Upon returning from the shower RT 1 disconnected Ambu bag and reconnected Resident 1 back to the ventilator. CNA 1 further stated she did not see the ventilator being turned on.

During an interview on [DATE], at 2:00 PM, with RT 1, RT 1 stated that on [DATE], he assisted with Resident 1's shower. RT 1 reported shower took approximately 30 minutes, from 10:30 AM to 11:00 AM. RT 1 stated, he disconnected Resident 1 from the vent and connected to Ambu bag to 10 liters per minute (L/min) of oxygen cylinder for transfer to shower gurney (hospital stretcher or transport bed).

Upon returning from the shower, RT 1 stated he reconnected Resident 1 to the ventilator, resumed ventilation from standby mode, and performed dressing change on tracheostomy. RT 1 further stated during routine rounds at 1:35 PM, RT 1 found Resident 1 was lying in bed, pale, eyes closed, unresponsive, no pulse or respirations, and the ventilator was on standby mode. RT 1 notified charge nurse and code blue started immediately.

During an interview on [DATE], at 2:25 PM, with CNA 2, CNA 2 stated that she was working with CNA 1 on [DATE], and helped with showering Resident 1. which took 30 minutes to complete the task. CNA 2 further stated RT1 connected Resident 1 back to the ventilator and changed tracheostomy dressing, but CNA 2 does not remember looking at the ventilator.

During a concurrent interview and record review on [DATE], at 2:25 PM, with Bio Med Technician (BMT), the facility's document titled, [Brand name] Ventilator [Serial number], Export timestamp: 2025-11-19_09-57-00, dated from [DATE], at 8:04 AM through [DATE], 1:55 PM, was reviewed.

The document indicated that the ventilator was on standby mode. BMT verified and confirmed that the ventilator was on Standby mode from 10:35 AM to 1:39 PM (3 hours and 4 minutes). A follow-up concurrent interview and record review on [DATE], at 2:35 PM, with BMT, the facility's document titled, OEM [Original Equipment Manufacturer] -Scheduled Preventative Maintenance, dated [DATE], was reviewed.

The document indicated that the scheduled preventative maintenance for [Brand name] Ventilator [Serial number], was conducted on [DATE]. BMT stated that there was nothing wrong with the ventilator. A review of Resident 1's Nursing Progress Note, dated [DATE], indicated, Resident 1 was transferred after the emergency response to ICU on [DATE], at 2:18 PM, for close observation and treatment.

During an observation of Resident 1 in ICU, on [DATE], at 2:45 PM, Resident 1 was observed lying in bed attached to ventilator, with FiO2 (the percentage of oxygen a person inhales with each breath with the maximum of 100 percent) set at 30 percent.

During a concurrent interview and record review on [DATE], at 3:10 PM, with the DCPS, the facility's document titled, [Brand name] Ventilator [Serial number], Export timestamp: 2025-11-19_09-57-00, dated from [DATE], at 8:04 AM, through [DATE], at 1:55 PM, was reviewed.

The document indicated that the ventilator was on standby mode.

The DCPS verified and confirmed RT 1 did not resume ventilation from standby mode. As a result, Resident 1 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.

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