Failure to Supervise Smoking Resident on Oxygen Results in Burns and Fire Hazard
Penalty
Summary
A facility failed to provide adequate supervision and maintain an environment free from accident hazards for a resident who required supervision while smoking. The resident, who had diagnoses including COPD, schizoaffective disorder, borderline personality disorder, intermittent explosive disorder, and anxiety, was assessed as cognitively intact and able to ambulate independently. Despite facility policies prohibiting smoking in resident rooms and the possession of lighters or cigarettes in rooms, the resident was repeatedly observed smoking in their room while receiving supplemental oxygen via nasal cannula. On one occasion, the resident sustained second-degree burns to the nose, fingers, and collarbone after lighting a cigarette while still wearing the nasal cannula, which ignited and caused a fire in the bed. Burned areas were noted on the bed sheets, mattress, and the resident's clothing. The resident reported that the nasal prongs ignited, burning the nose, and that the sheets and mattress caught fire, which the resident attempted to extinguish. The facility's records showed that the care plan was not updated to reflect the resident's ongoing noncompliance with smoking policies or the incident of injury, and no new interventions were documented. Interviews with facility leadership revealed that staff were aware of the resident's continued access to cigarettes and lighters, as well as ongoing unsupervised smoking in the room, but no investigation was conducted to determine the source of the contraband. The DON expressed uncertainty about how to prevent residents from bringing in lighters and was not familiar with facility policies regarding contraband. The resident stated that cigarettes and lighters were obtained during outings with staff and from other residents, and that no one from the facility had inquired about the source. Despite repeated education, the resident continued to smoke in the room, and the facility did not implement additional interventions or update the care plan accordingly.