F0726

D

Nursing Staff Lacked Competency in Operating Portable Oxygen Tanks

Holyoke, Massachusetts Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

Nursing staff failed to demonstrate competency in setting up and operating portable oxygen equipment for a resident who experienced acute shortness of breath. The facility’s oxygen administration policy required staff to assemble a portable oxygen cylinder and regulator, turn on the oxygen, and then apply the appropriate delivery device. A resident with diagnoses including congestive heart failure, chronic kidney disease, and diabetes reported being unable to breathe while on room air. Nursing assessment found the resident’s oxygen saturation to be low, and a nurse directed another nurse to obtain a portable oxygen tank from the unit’s code cart. The nurse reported that the regulator gauge on that tank showed it was empty, and a second tank obtained from another unit was also reported as appearing empty.

Subsequent review and interviews revealed that neither oxygen tank was actually empty. The Staff Development Coordinator later inspected the tanks and stated that if the tank valve was not fully opened with the metal key on top of the tank, the regulator gauge would not accurately display the remaining oxygen and could falsely appear empty. In an interview, the nurse who retrieved the tanks admitted she did not know she needed to twist the top of the oxygen tank with the metal key to turn the oxygen on so that the gauge would show the true amount of oxygen available. Although facility leadership and the Staff Development Coordinator stated that this nurse had completed all required clinical competencies upon hire, including the steps needed to prepare a portable oxygen tank for use, the incident demonstrated that the nurse was unaware of the need to open the tank valve with the key in order to access and administer oxygen to the resident.