Resident Burned While Smoking with Oxygen Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease and moderate cognitive impairment sustained first and second degree burns to the face after smoking while using oxygen. The resident, who was dependent on renal dialysis and used a wheelchair, returned from on-site dialysis with a portable oxygen tank and entered the designated outdoor smoking area. Despite facility policy prohibiting smoking while oxygen is in use and requiring supervision by designated smoking monitors, the resident was able to access the smoking area with oxygen in use and obtained a cigarette from another resident. At the time of the incident, there was a Bar-B-Q event in the courtyard, resulting in increased activity and a higher volume of residents in the area. The smoking monitors assigned to supervise the area were occupied with multiple tasks, including writing down names of residents entering the courtyard, assisting residents in wheelchairs, and responding to reports of marijuana use. During this period of heightened activity, the resident was not adequately supervised and managed to light a cigarette while the nasal cannula was still in place, causing the oxygen to ignite and resulting in burns. Staff interviews confirmed that the smoking monitors were distracted by other duties and did not notice the resident entering the courtyard or smoking with oxygen in use. The incident was only discovered when a staff member observed a flash and saw the resident's face was burned. The lack of direct supervision and failure to enforce the facility's smoking policy directly contributed to the resident's injury.