Failure to Prevent Accident Hazard Due to Resident Possession of Fire Lighter
Penalty
Summary
A fire lighter was observed in a transparent bag next to a resident who was seated in the activities room among other residents. The resident, who is cognitively intact and requires partial to moderate assistance for eating, was not identified as a smoker in their clinical records or Minimum Data Set (MDS) assessment. When questioned, the resident declined to explain the presence of the lighter. The assigned CNA was unaware of the lighter and did not know if the resident smoked. The Registered Nurse Manager was notified and immediately removed the lighter, confirming that the resident was not permitted to have it and was not a smoker. The facility's policy requires the environment to be as free of accident hazards as possible and mandates adequate supervision to prevent accidents, including identifying and removing hazards. Despite daily rounds intended to identify hazardous materials, the lighter was not detected until observed by the surveyor. The Director of Nursing noted that the resident was previously homeless and resistant to staff handling his belongings, but could not explain how the lighter was acquired. This incident demonstrates a failure to provide adequate supervision and to ensure the environment was free from accident hazards as required by facility policy.