Failure to Supervise Cognitively Impaired Smoker Leads to Burns and Unsupervised Exit
Penalty
Summary
A deficiency occurred when a facility failed to provide effective supervision and accident prevention for a resident with severe cognitive impairment, hemiparesis, and a history of smoking. The resident had previously been assessed as requiring supervision while smoking due to limited range of motion, weak grasp, and unclear speech, but a subsequent assessment determined the resident could smoke unsupervised. This change was made despite no improvements in the resident's cognition or functional abilities. As a result, the resident was allowed to smoke unsupervised in the designated area. While smoking unsupervised, the resident caught her hair on fire, resulting in singed hair, a blistered eyelid, and mild burns to her hand and behind her ear. The incident was observed by staff after the fact, and the resident required topical treatment for her injuries. The assessment following the incident determined the resident was unable to safely light or hold smoking materials and could not call for emergency assistance, leading to a change back to supervised smoking. Additionally, the resident exited the facility unsupervised in her wheelchair, traveling through the parking lot toward a main road without staff knowledge. She was found by staff after a visitor alerted them, and she stated she was attempting to go smoke. The resident did not have smoking materials in her possession and denied trying to leave the facility, indicating she was seeking staff attention to be taken to smoke. The facility had not identified her as a wander or elopement risk, and there were no interventions in place to prevent her from leaving the building unsupervised.
Removal Plan
- The facility initiated a therapy referral for positioning while in wheelchair for Resident #3.
- Therapy followed resident with plan of treatment.
- The Responsible Person was notified of the incident, follow up treatment plan, and change in supervision with smoking with resident's consent.
- Resident's smoking assessment was re-evaluated by charge nurse and resident was notified that she was now a supervised smoker; resident verbalized understanding and agreement.
- Staff notified of change in supervision with smoking and residents' apparatus by the Director of Nursing.
- Director of Nursing updated smoking binder that is in nurse's stations, front office, and therapy department.
- The facility ordered resident #3 a smoking adaptive apparatus to hold her cigarette.
- Being a supervised smoker, staff will light Resident #3's cigarettes.
- Resident's care plan/kardex updated to reflect that her hair is pulled back per resident acceptance.
- Smoking apron available per resident's acceptance.
- Facility will honor resident's rights and preferences while providing supervision to promote safety.
- The Unit Manager assessed resident for wandering tendencies and determined resident did not present as a risk; resident was provided with a cigarette in designated smoking area.
- Residents' preference for smoking times to be honored per request with staff supervision.
- Facility made aware that resident did not prefer the smoking apparatus and discontinued the apparatus; resident can safely hold a cigarette with supervision.
- Skin assessments were completed on all residents who smoke to ensure no burns identified from smoking; assessments completed by licensed nurses.
- The Director of Nursing and licensed nurses re-assessed all residents who wish to smoke for need of supervision and/or adaptive equipment; no additional residents were noted.
- The Director of Nursing and licensed nurses reviewed care plans and Kardex's for all supervised and unsupervised smokers to ensure up to date and accurate with no additional concerns noted.
- The charge nurse completed a resident headcount to ensure that all residents were accounted for.