Failure to Prevent Resident Access to Hazardous Items Resulting in Fire
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment free from accident hazards, resulting in a cognitively impaired resident starting a fire in her room using a cigarette lighter. The resident, who had a history of dementia with behavioral disturbances, confusion, and impaired cognitive function, was able to access and retain multiple lighters in her room. Despite care plans indicating the need for supervision and the use of a WanderGuard due to elopement risk, the resident was left unsupervised in her room, where she ignited her recliner, triggering the facility's smoke alarm. Staff discovered the fire after noticing a glare from the resident's room. Upon entering, they found the resident in her wheelchair next to the burning recliner. The fire was extinguished by CNAs with the assistance of a resident's representative, and all residents were evacuated from the building. Subsequent inspection of the resident's room revealed not only multiple lighters but also various items belonging to other residents, including medical equipment and scissors, indicating a lack of effective monitoring of potentially hazardous items. Interviews and documentation confirmed that the resident had a history of confusion, hallucinations, and delusions, and her cognitive assessments fluctuated from intact to severely impaired. Staff and administrative interviews indicated that the facility was unaware of how the resident obtained the lighters and that there was no effective system in place to prevent unsafe items from entering resident rooms. The failure to supervise the resident and control access to hazardous items directly led to the fire and placed all residents in immediate jeopardy.