CM5000

Description of Event or Problem

HOME HEALTH CAARE WORKER REMOVED ONE AIRWAY PRESSURE MONITOR AND CONNECTED UNIT RETURNED FROM REPAIR, PRIOR TO OPERATIONAL CHECK-OUT, TO PATIENT. UNIT FAILED TO ALAARM WHEN PATIENT STOPPED BREATHING. PATIENT TURNED BLUE BUT WAS ATTENDED TO BY THE HOME HEALTH CARE WORKER ESTIMATES THAT ONE MINUTE PASSED FROM THE TIME SHE NOTICED THE ATIENT IN DISTRESS. THE PATIENT IS MENTALLY RETARDEDD WITH MULTIPLE HEALTH PROBLEMS. CURRENTLY BEING TREATED FOR RESPIRATORY AILMENT WHICH HAS PRODUCED THICK SECRETIONS WHICH TH EHEALTH CARE WORKER STATES BLOCKED THE TRACH.