Failure to Prevent Smoking-Related Accidents Involving Oxygen Use
Penalty
Summary
The facility failed to ensure that two residents were free from injuries resulting from a preventable accident related to smoking while using supplemental oxygen. One resident, who had multiple medical diagnoses including myocardial infarction, acute respiratory failure, COPD, psychotic disorder, and burns, was assessed as a safe smoker and allowed to smoke independently. Despite a facility policy prohibiting smoking in areas where oxygen is administered or stored, the resident was outside smoking with oxygen tubing in place when he dropped his cigarette, igniting his clothing and oxygen tubing. The fire resulted in second and third degree burns to his right hip, thigh, and flank, requiring emergency medical attention. The resident stated he could not assist himself due to lack of legs, and friends had to intervene to extinguish the fire. Another resident, with diagnoses including orthostatic hypotension and COPD, was also assessed as a safe smoker and permitted to keep his own smoking materials. During the incident, this resident provided a cigarette to the first resident and attempted to extinguish the fire when it broke out, sustaining burns to his own hand in the process. Documentation showed inconsistencies in the evaluation and storage of smoking materials for this resident, as the evaluation indicated he did not require supervision, but also stated the facility would store his lighter and cigarettes. Interviews revealed that both residents were considered cognitively intact based on BIMS scores, and staff relied on these assessments to determine their ability to smoke safely without supervision. The facility's process for evaluating safe smokers involved observing residents' ability to handle cigarettes and lighters, and their cognitive awareness of smoking procedures. However, staff interviews indicated uncertainty regarding whether oxygen was turned off prior to smoking, and there was a lack of direct staff supervision during the incident. The facility's policy required oxygen to be turned off and nasal cannula removed before smoking, but this was not verified at the time of the accident. Additionally, residents and staff noted the absence of clear signage in the smoking area regarding oxygen safety, and residents expressed trauma and distress following the event.