Community Hospital of San Bernardino D/P SNF
1805 Medical Ctr Dr., San Bernardino, CA 92411
Citation Number: 240008216
Citation Date: 5/6/2011
Violation Date: 2/2/2008
Class: AA
Penalty: $ 80,000

On 2/2/08, a resident who was ventilator dependent died when the ventilator tubing became disconnected, the alarm did not function and the staff did not respond appropriately to the life-threatening situation. A nursing assistant summoned a nurse after observing a serious change in the resident's condition, but the nurse left after stating the resident was "o.k." A few minutes later, a respiratory therapist discovered that the tubing to the resident's ventilator was disconnected and not functioning. The tubing was reconnected, but the resident did not recover and died about 15 minutes later. A second respiratory therapist reported he had not performed a "vent check" yet that morning, however, the therapist stated that he documented otherwise because the Respiratory Care Manager "made me write the vent check." According to facility training records, the nurse who responded to the resident did not have an annual competency for ventilator dependent residents. The facility was cited because it failed to ensure that staff caring for ventilator dependent residents were qualified, it failed to ensure that staff caregivers maintained yearly competency, it failed to ensure staff performed ventilator checks every four hours as required, and its staff failed to continually assess the resident after his respiratory condition changed. As a result, the resident died.