Unlabeled Hummingbird Water Used in CPAP Humidifier
Penalty
Summary
The deficiency involves the facility’s failure to keep the resident environment as free of accident hazards as possible and to provide adequate supervision to prevent accidents, specifically related to the use of a CPAP machine. An elderly female resident with severe cognitive impairment, dementia, and a diagnosis of obstructive sleep apnea required nightly CPAP therapy with distilled water in the humidifier reservoir, as ordered by her physician and reflected in her care plan. The care plan and facility policy required the CPAP humidifier to be filled with fresh distilled water in the evening before use. Despite this, a large plastic bottle containing a mixture of tap water and granulated sugar, prepared by the family as hummingbird water and stored under the resident’s refrigerator near bird seed, was present in the resident’s room in a container labeled as purified water. On the evening in question, video evidence showed an RN entering the resident’s room, waking the resident, and assisting her with the CPAP mask. The RN observed that the CPAP water reservoir was empty and did not see the usual distilled water bottle on the nightstand or floor. The RN searched the room, verbally asked where the water was, and then located a bottle labeled purified water under the refrigerator. Without verifying that it was distilled water or otherwise confirming its contents, the RN poured this liquid into the CPAP reservoir and returned the bottle to its place. The RN later stated she believed purified water was acceptable because it was not tap water, acknowledged that purified water is not the same as distilled water, and reported she had not received specific CPAP training at the facility. She also reported attempting to clean the reservoir with water and tissues after being informed that the bottle contained hummingbird water. Subsequent interviews and observations confirmed that the bottle used by the RN was the family’s hummingbird water, which had been in the room since approximately July of the previous year. The resident’s responsible party reported this to staff, prompting another nurse to enter the room, remove the CPAP from the resident, and take the hummingbird water bottle to the medication room. Staff, including the RT, MD, FNP, and DON, described the mixture as tap water and sugar stored in a bottle labeled purified water and noted that it was not clearly labeled as hummingbird water. The RT and other clinicians explained that CPAP humidifiers are intended to be filled with sterile or distilled water and that the presence of this sugar-water mixture in the machine could lead to bacterial buildup over time. The facility’s own CPAP/BiPAP policy specified the use of distilled water in the humidifier, but this was not followed when the RN used the unlabeled hummingbird water from the resident’s room in the CPAP reservoir.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.