Failure to Supervise Smoking Resident Results in Fire and Injuries
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two of seven sampled residents. One resident, who had a physician's order and care plan requiring one-to-one supervision while smoking due to a seizure disorder and potential for injury, was left unattended in the designated smoking area by a PRN physical therapist. The therapist, who was not aware of the supervision requirement, left the resident with cigarettes and a lighter and returned inside the facility. There were no other staff present in the smoking area at the time. While unsupervised, the resident's shirt caught on fire. Another resident attempted to extinguish the flames with his hand but was unsuccessful, resulting in burn injuries to his own hand. A third resident alerted staff by shouting for help. Staff responded by bringing a smoking blanket and a fire extinguisher, and the nurse used the blanket to put out the flames. The fire department arrived within 5-10 minutes, and the resident who caught fire was transported to the hospital with significant burn injuries. The second resident sustained burns to his fingers while trying to help. The facility's investigation confirmed that the resident who required supervision was left alone due to a lack of communication and understanding of the care plan by the PRN therapist, who primarily worked at another facility. The Director of Nursing acknowledged that the staff were unaware of the resident being left unsupervised and that the required supervision was not provided, resulting in injuries to both residents involved.