Resident Sustains Severe Burns Due to Lack of Supervision During Smoking
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including hemiplegia, peripheral vascular disease, dementia, and cognitive communication disorder, was allowed to smoke unsupervised, resulting in life-threatening injuries. The resident had a care plan in place identifying the potential for injury related to smoking, with interventions such as maintaining smoking materials at the nurses' station and monitoring compliance with the facility's smoking policy. The resident was assessed as cognitively intact and had a recent smoking assessment indicating the need for supervision and use of a smoking apron. Despite these interventions, the resident accessed the smoking patio alone, outside of designated supervised smoke break times, and was able to obtain smoking materials. Staff interviews confirmed that the facility's policy required staff to hold all smoking paraphernalia and supervise residents during scheduled smoke breaks. However, on the day of the incident, the resident was found on the patio without staff supervision, and his blanket caught fire, resulting in burns to his face and neck. The incident was discovered by a staff member passing by, who called for help and attempted to extinguish the fire. The facility's smoking policy explicitly stated that residents were not allowed to keep smoking materials on their person and that all smoking was to be supervised at specific times. The failure to adhere to these protocols led to the resident sustaining third-degree burns and requiring emergency medical attention. Staff interviews and documentation confirmed that the resident was not being supervised at the time of the incident, and the most recent smoking assessment was not provided upon request.