Failure to Prevent Accident Hazard Involving Oxygen and Smoking Materials
Penalty
Summary
A deficiency occurred when the facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents for a newly admitted resident. The resident, who had a history of smoking, multiple rib fractures, and falls, was admitted with these risk factors known to the facility. Despite this, the resident was able to access and use a personal lighter in their room while on oxygen therapy. This resulted in the resident accidentally igniting their oxygen tubing, causing a minor fire that damaged the floor and the oxygen concentrator. Surveyor observations confirmed physical evidence of the incident, including a discolored area on the floor and photographic documentation of burnt oxygen tubing and burn marks on the oxygen concentrator. Interviews with facility leadership revealed that the facility was aware of the resident's smoking history at admission but could not provide evidence that appropriate measures were taken to minimize accident hazards or provide adequate supervision. The resident confirmed using the lighter to find shoes in the dark, which led to the fire.