F0695

D

Failure to Maintain Oxygen Humidifier Water Level for Resident on Continuous O2

Webster, Texas Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

Surveyors found that a resident with diagnoses including hypertension, hyperlipidemia, shortness of breath, pneumonia, and respiratory failure, and an order for continuous oxygen at 4 L/min via nasal cannula, was not provided oxygen therapy consistent with professional standards of practice. Record review showed the resident used oxygen therapy and had care plan interventions to monitor for signs and symptoms of respiratory distress and to provide oxygen at 4 L via nasal cannula. The resident’s MDS indicated significant cognitive impairment, including short- and long-term memory problems and that he was rarely/never understood, and he required substantial/maximal assistance for personal hygiene and transfers.

On observation, the resident was wearing a nasal cannula and the oxygen concentrator was set at 4 L/min, but the humidifier bottle attached to the concentrator was completely empty. An LVN confirmed during interview that the bottle should contain water for humidification to prevent nasal irritation and acknowledged that the bottle for this resident was out of water. The LVN stated that humidifier bottles are typically full for two days and that he had been off for a few days. Another LVN reported she had worked with the resident the previous two nights, that she checked the humidifier bottle and had filled it two days prior, and that it was about half full when she left the previous night. The DON stated there should be water in the oxygen concentrator bottle to humidify the nasal passages and that nurses should notice when the water is low and refill it. The facility’s oxygen therapy policy stated that all oxygen administration is to be conducted in a safe manner and that distilled water is to be used for humidification.