Failure to Prevent and Investigate Repeated Fire Incidents Involving Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to thoroughly investigate and implement effective interventions following multiple fire incidents involving a resident with severe cognitive impairment. The resident, who had a history of wandering, collecting items, and previous smoking, was found with a lighter and was involved in several fire-related incidents, including a fire on a mattress, burn spots on privacy curtains, and a toilet tissue roll set on fire in his bathroom. Despite these events, staff did not consistently monitor the resident or his room for fire-starting materials, nor did they ensure that interventions such as the use of lock boxes for smoking materials were properly implemented for all residents. Clinical records and staff interviews revealed that the resident was severely cognitively impaired, with a low BIMS score, and was unable to recall the fire incidents or how he obtained lighters. Documentation showed that after each incident, staff searched the resident and his room but failed to identify how the resident continued to access fire-starting materials. There was also a lack of consistent and ongoing supervision, as the resident was observed unsupervised in his room and wandering the halls. Staff interviews indicated a lack of awareness and education regarding the need to monitor the resident and inspect his belongings for lighters or other fire-starting materials. Additionally, the facility did not ensure that all residents who smoked used lock boxes for their smoking materials, and some residents left their lock boxes unlocked or did not use them at all. Staff did not routinely inquire whether other residents had been approached for lighters or smoking materials, and there was no documentation of a thorough investigation into how the resident obtained these items. The facility's failure to implement and maintain effective supervision and safety interventions resulted in repeated fire incidents and placed all residents at risk.