Failure to Supervise Resident Smoking with Oxygen Resulting in Fire and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for a resident with a history of nicotine dependence and chronic obstructive pulmonary disease who continued to smoke while using oxygen. Despite multiple documented instances where the resident expressed intent to smoke and was observed smoking on facility property, the care plan did not address the resident's risk factors related to smoking while on oxygen. Staff were aware of the resident's behavior, and there were several notes indicating the resident's frustration with smoking restrictions and attempts to smoke, including while on oxygen. The facility's policies required comprehensive care planning and strict adherence to oxygen and smoking safety, but these were not effectively implemented for this resident. On the date of the incident, the resident's wheelchair caught fire in the facility parking lot while the resident was smoking with oxygen in place, resulting in burns to the resident's upper legs, abdomen, nostrils, and hands. Other residents witnessed the event and intervened to help the resident. Staff interviews confirmed prior knowledge of the resident's unsafe smoking practices and lack of care plan interventions addressing these risks. The facility's smokefree policy and procedures for handling residents who refuse to follow safe smoking practices were not enforced in this case.