F0689

L

Failure to Control Resident Smoking in Rooms Resulting in Fire

Kensington, Maryland Survey Completed on 02-09-2026

Penalty

Fine: $27,270

Summary

The deficiency involves the facility’s failure to maintain an effective system to prevent residents from smoking in their rooms, which resulted in a fire in a resident room. One resident with diagnoses including unspecified psychosis and non-compliance with medication was documented on a change in condition note as being observed continuously smoking in the room and hallway, refusing redirection and continuing to smoke in the room shared with another resident. A subsequent behavior note indicated this same resident refused a head-to-toe assessment three times after the fire marshal noted smoke coming from the resident’s mattress. Staff interviews confirmed that this resident had been seen smoking in the room on multiple occasions in the week prior to the fire.

Another resident, admitted with a diagnosis including tobacco use, was documented in multiple change in condition notes as picking cigarette butts from the trash on the smoke porch and being observed smoking multiple times in the room, bathroom, another resident’s room, and the hallway. This resident was repeatedly redirected but refused to comply, stating they had the right to smoke anywhere and did not care about the adverse effects of smoke on non-smokers. Nursing documentation also noted that this resident continued to smoke in the room, cursed at staff when confronted, and would not yield to teaching. Staff interviews corroborated that this resident had been seen smoking in the room in the week prior to the fire and that attempts to obtain smoking materials were met with aggression and refusal.

A third resident, with diagnoses including tobacco use, intermittent explosive disorder, opioid abuse, bipolar disorder, and generalized anxiety disorder, was documented in a nursing note as being observed smoking in the room and receiving education about the danger of such behavior. Despite a facility policy that residents could not have smoking materials in their rooms and that smoking materials were to be stored on a cart and obtained from social services or nursing at designated times, staff interviews revealed that residents were still able to obtain and keep smoking materials. One staff member reported seeing two residents with lit cigarettes in the hallway who then went into a room and blocked the door, and another staff member reported finding a resident smoking in the room on two separate occasions, once without reporting it because no one was present at the nurses’ station. After the fire, a resident previously known to smoke in the room was observed with two cigarette lighters on the bedside table, confirmed by the nurse, indicating ongoing access to smoking materials in resident rooms.

Interviews with the ADON, DON, and social worker showed that facility leadership was aware that some residents were non-compliant smokers and that residents with known behaviors of smoking in their rooms existed prior to the fire. The ADON acknowledged that residents were supposed to have their cigarettes and lighters stored on a cart and be supervised on the smoke porch, but stated that some residents did not follow the rules and that the facility used behavioral contracts and medical/psych consults when residents did not comply. The DON stated that residents sometimes secretly brought smoking materials into the building and that no one knew how the resident involved in the fire obtained them. The social worker confirmed that certain residents had known behaviors of smoking in their rooms and that no residents were supposed to have smoking materials in their rooms. Observation of the unit showed posted smoking schedules that left a long period with no scheduled smoking times, while multiple residents with tobacco use and behavioral issues continued to smoke in their rooms and hallways despite staff awareness and prior documentation, culminating in a fire in a resident room.

Removal Plan

• Review the facility smoking policy with all identified smoking residents.
• Ask all residents to turn in all smoking materials.
• Visually inspect all resident rooms for smoking materials.
• Place any collected smoking materials in the smoker's box.
• Assign Residents #1, #2, and #3 to one-on-one supervision due to refusal to turn in smoking materials.
• Maintain one-on-one supervision for Residents #1, #2, and #3 until they no longer have smoking materials in their possession and demonstrate no behaviors of smoking in their rooms.
• Educate all staff that residents may not have any smoking materials on them.
• Educate all staff that residents may only smoke at designated smoking times in the designated area.
• Educate all staff that if they become aware of a resident smoking in their room or having smoking materials on them, they are to ask the resident for the materials.
• Require that if a resident refuses to turn in smoking materials, the resident is placed on one-on-one supervision immediately and the staff member notifies the Executive Director or nursing supervisor.
• Audit nursing notes of identified residents who smoke in the daily clinical meeting for documentation of illegal smoking activity.
• Inspect the room of each resident identified as a smoker for smoking materials or evidence of smoking in the room.
• Have the Executive Director audit all Ambassador round reports for residents identified as smokers.
• Have the Director of Nursing audit all nurses' notes to evaluate whether violations of the smoking policy have been discovered.
• Submit audit results to the Quality Assurance and Performance Improvement Committee for review and approval.