F0695

D

Improper CPAP Humidifier Water Use and Interruption of Ordered CPAP Therapy

Waco, Texas Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards and the resident’s care plan for a resident requiring CPAP therapy for obstructive sleep apnea. The resident was an elderly female with severe cognitive impairment, dementia, and a cognitive communication deficit, who had a physician’s order for nightly CPAP use at a prescribed setting. A prior sleep study documented severe obstructive sleep apnea with numerous obstructive apneas and hypopneas, significant respiratory arousals, and oxygen desaturations, leading to the order for nightly CPAP use. The resident’s comprehensive care plan required that the CPAP humidifier reservoir be filled with distilled water only each night and that the CPAP equipment be cleaned according to specified procedures.

On the evening in question, RN A entered the resident’s room, woke the resident, and had her apply the CPAP mask. RN A observed that the CPAP water reservoir was empty and did not see the usual distilled water bottle on or near the nightstand. Instead of obtaining distilled water from the medication room as per her training and facility practice, RN A located a bottle labeled “purified water” under the resident’s refrigerator and used it to fill the CPAP reservoir. This bottle was later identified as hummingbird water, a mixture of tap water and granulated sugar that had been prepared by the family months earlier and stored near bird seed in the resident’s room. Video footage showed RN A searching for water, picking up a blue-labeled bottle from beneath the area of the camera, pouring its contents into the CPAP reservoir, and returning the bottle to where she found it.

RN A acknowledged in interview that she knew purified water was not the same as distilled water and that she had been trained that distilled or sterile water was to be used in CPAP humidifiers. She stated she thought using purified water was acceptable because it was not tap water and reported attempting to clean the reservoir with water and tissues after being informed that the bottle contained hummingbird food. The respiratory therapist confirmed that CPAP humidifier water should be sterile or distilled and that she had initially set up the resident’s CPAP. Following discovery of the incident, the resident’s CPAP was taken out of service, and the resident was without CPAP use for at least one night. Medical providers, including the RT, MD, and FNP, described the situation as dangerous or potentially problematic if the sugar water mixture were used repeatedly, and the facility’s own policy specified that the humidifier chamber was to be refilled with fresh distilled water in the evening before use. These actions and inactions by RN A, and the presence of an unlabeled or misleadingly labeled container of hummingbird water in the resident’s room, led directly to the deficiency in providing safe and appropriate respiratory care.

The deficiency also included the resident being without her prescribed CPAP therapy for at least one night after the machine was removed from service. The RT stated it was her understanding that the resident had been without CPAP for two nights, and the DON stated the resident went one night without CPAP after it was taken out of service and before a replacement machine was delivered and used. The resident herself reported that she did not wear her CPAP often and did not recall the incident. Nonetheless, the documented physician order required nightly CPAP use, and the care plan interventions were based on the resident’s severe obstructive sleep apnea. The combination of using an inappropriate fluid in the CPAP humidifier and the subsequent interruption of ordered CPAP therapy constituted the failure to provide respiratory care in accordance with professional standards and the resident’s care plan.

Interviews with staff further clarified the circumstances leading to the deficiency. LVN B reported that she did not usually work on the resident’s hall and was unaware that hummingbird water was kept in the room. After being notified by the resident’s representative that hummingbird water had been poured into the CPAP, she entered the room, removed the CPAP from the resident, and took the hummingbird water to the medication room, noting that the room was somewhat dark and that the water appeared discolored. The DON stated that the hummingbird water bottle was not clearly labeled, that the water appeared cloudy, and that the facility sometimes used similar bottles for distilled water obtained from a supplier or grocery store. The facility’s policy on CPAP/BiPAP support required the humidifier chamber to be emptied, rinsed, and refilled with fresh distilled water in the evening, underscoring that the use of hummingbird water and the failure to ensure availability and correct identification of distilled water in the resident’s environment were central factors leading to the cited deficiency.