F0695

D

Failure to Ensure Adequate Portable Oxygen for Oxygen‑Dependent Resident During Dialysis Transport

Cleveland, Ohio Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate oxygen for a resident who was oxygen‑dependent during outside dialysis appointments. The resident had multiple diagnoses including end stage renal disease, paraplegia, acute and chronic respiratory failure with hypoxia, hypertension, type 2 diabetes, and psychosis, and used continuous oxygen via nasal cannula. Physician orders included dialysis three times weekly and continuous oxygen at five liters per minute via nasal cannula. The resident’s care plan identified the need for oxygen related to chronic respiratory disease and directed staff to observe for signs and symptoms of dyspnea. The facility’s oxygen administration policy addressed oxygen use under physician orders but did not address oxygen management for residents during appointments outside the facility.

On the day of the incident, the resident completed dialysis treatment in the early afternoon and was placed back on the portable oxygen tank supplied by the facility while waiting in the dialysis center lobby for transportation back to the facility. Dialysis staff reported that the portable oxygen tank from the facility was not full and that the resident frequently arrived with insufficient oxygen to last through the return trip, often running out while waiting for transportation. On this occasion, while waiting in the lobby, the resident’s portable tank became empty, and he began complaining that he was not getting oxygen, became upset, crying, and exhibited distress such as huffing and puffing. Dialysis staff confirmed the tank from the nursing home was empty and placed the resident on the dialysis center’s oxygen concentrator, which improved his condition.

Dialysis staff made multiple attempts to contact the facility to obtain a replacement oxygen tank. After several unanswered calls, they reached an LPN at the facility and explained that the resident’s tank was empty and he required oxygen. According to dialysis and EMS documentation, the facility nurse stated there was no way to bring a replacement tank in time, and transportation staff were unwilling to wait and did not have portable oxygen available. The dialysis center had only one E‑tank with the crash cart and otherwise used plug‑in concentrators, so they could not provide portable oxygen for transport. Following back‑and‑forth communication between dialysis staff and the facility nurse, and with the dialysis center closing and transportation leaving, the decision was made, with the facility nurse’s agreement, to call 911 and send the resident to the emergency department solely because he had run out of oxygen and no replacement tank was provided. EMS documentation and the resident’s own statements indicated that this was not the first time he had been sent out from the facility with a partially filled oxygen tank and had run out of oxygen while away from the facility.

The EMS run sheet documented that EMS arrived to find the resident in the dialysis lobby on supplemental oxygen from the dialysis center’s concentrator, with oxygen saturation at 97% on oxygen. EMS noted that the resident was oxygen‑dependent at three liters per minute and that his portable tank from the facility had run out while he was waiting for his ride. EMS contacted the facility en route and were told again that staff had instructed dialysis to call 911 because the resident could not stay at the dialysis center and transportation would not wait. The emergency department after‑visit summary recorded that the resident was seen for running out of oxygen and that no emergency medical condition was identified at that time. In a later telephone interview, the resident reported that while at the facility he repeatedly ran out of oxygen because he was given “half‑tanks,” and he described being very upset when he ran out of oxygen at dialysis and transportation refused to take him without oxygen.