Failure to Supervise Unsafe Smoking Practices for Resident on Oxygen
Penalty
Summary
The facility failed to provide effective supervision and implement adequate interventions for a resident who was assessed as unsafe to smoke without supervision and had a known history of non-compliance with the facility's smoking policy. Despite being on continuous supplemental oxygen therapy for chronic respiratory failure and COPD, the resident was repeatedly observed by staff smoking in undesignated areas while using a portable oxygen tank via nasal cannula. These incidents were reported to facility leadership, but no new interventions or increased monitoring were implemented to prevent recurrence, and the resident's care plan did not document his non-compliance or address the ongoing risk. On multiple occasions, the resident exited the facility independently and smoked with his oxygen in use, both alone and in the presence of another resident. Staff removed the oxygen tank when they discovered these incidents, but no harm occurred until a later event when the resident's shirt caught fire while smoking with oxygen in use. The resident sustained a flash burn to his face and upper lip, requiring evaluation in the emergency department. Interviews with staff revealed inconsistent awareness of the resident's supervision requirements, lack of communication regarding his non-compliance, and failure to ensure that staff responsible for supervision were informed of which residents required monitoring during smoking times. The facility's smoking policy prohibited smoking in all but designated areas and specifically forbade oxygen use in those areas. However, the resident was able to obtain cigarettes from visitors and access exit doors with codes known to residents and visitors. Staff and leadership acknowledged breakdowns in the smoking supervision process, including lack of effective monitoring, failure to update care plans with non-compliance information, and inadequate enforcement of the smoking policy. The deficiency affected multiple residents reviewed for smoking, and immediate jeopardy was identified due to the facility's failure to implement effective interventions after repeated incidents.