F0695

D

Failure to Provide Ordered Oxygen During Resident Transport to Outpatient Procedure

Woodstock, Illinois Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident who was on continuous oxygen at 2 L/min via nasal cannula received appropriate oxygen services during transportation to an outpatient procedure. The resident had diagnoses including COPD, chronic respiratory failure with hypoxia, chronic diastolic congestive heart failure, and dementia, and was observed in the facility with oxygen at 2 L/min via concentrator. A health status note documented that the resident received chronic 2 L nasal cannula oxygen for COPD. The facility’s receptionist/transportation coordinator contacted the resident’s insurance and requested transportation services that included 2 L of oxygen, and the insurance representative confirmed that this request was made.

The transportation dispatcher/operations manager confirmed that the transportation arranged was a non-emergency medical stretcher ride that did not provide oxygen on the vehicle, but stated the facility could provide oxygen and that the stretcher could hold a travel oxygen tank. When the transportation driver arrived, the resident was lying in bed without oxygen in place, and facility staff did not indicate that the resident required oxygen or provide an oxygen canister for the trip. The driver transferred the resident to the stretcher and transported the resident without oxygen, reporting no observed shortness of breath or distress during the trip. The manager of care coordination reported that the resident arrived at the hospital for outpatient surgery with an oxygen saturation below 90%, and the first recorded saturation was 91% after oxygen via nasal cannula was provided. The nurse practitioner stated the resident had a history of COPD and chronic hypoxic respiratory failure and would prefer the resident be transferred to hospital appointments with oxygen.