F0689

J

Failure to Control Smoking Materials and Prevent Oxygen-Related Fire

Minneapolis, Minnesota Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent an unintentional fire and to control smoking materials for a resident who used continuous oxygen and had documented dementia with moderate cognitive impairment. The resident’s diagnoses included pulmonary fibrosis, COPD, depression, nicotine dependence, and dementia. A smoking evaluation dated 12/19/25 identified the resident as safe to smoke independently, with no cognitive loss, no visual or dexterity problems, and allowed her to store and handle her own cigarettes and lighter. This evaluation did not address whether the resident understood safety measures related to removing or positioning oxygen equipment prior to smoking. The initial smoking care plan, initiated 12/23/25, set a goal for the resident to smoke safely and independently, noted education on the dangers of oxygen and smoking, and stated she was independent with smoking per evaluation, but did not include specific interventions regarding oxygen placement or removal before or during smoking.

On 12/24/25, the resident was found smoking in her room, contrary to facility expectations. The incident analysis identified that she was a new admission and independent with smoking per her admission form. She was re-educated, and the plan was to remove smoking materials and keep them at the nursing station. A smoking evaluation dated 12/24/25 again documented no cognitive loss despite the MDS showing moderate cognitive impairment and a dementia diagnosis, and it specified that the resident could light her own cigarette but could not store her own smoking materials, which were to be kept at the nursing station. However, the smoking care plan was not revised until 12/29/25 to add the intervention to store smoking materials at the nurse station. A Risk vs Benefits form dated 12/30/25 identified the concern of the resident smoking in her room while on oxygen and described the dangers of oxygen-related fires, but it did not list any benefits, was not signed by the resident or representative, and there was no documentation of monitoring or evaluation of the effectiveness of the intervention to store smoking materials at the nurse’s station.

On 1/29/26 at 8:39 a.m., progress notes documented that the resident was smoking in her room and caused a fire, indicating that the 12/29/25 intervention to keep smoking materials at the nurse’s station was not followed. The resident denied smoking and refused a respiratory assessment and skin check. An incident analysis for 1/29/26 stated that staff heard the roommate yelling for help and found a fire on the resident’s oxygen tank in her room while the resident was smoking, though she denied it. The fire was extinguished, and both residents were assessed with no injuries found. A search of the room revealed a pack of cigarettes, which was taken to the nurse’s station. The smoking evaluation dated 1/29/26 again documented no cognitive loss despite the MDS and dementia diagnosis, noted that the resident smoked 5–10 times per day, could light her own cigarette, could not store her own smoking materials, and that smoking materials were supposed to be kept at the nurse’s station. It also stated that daily room checks were to be done, that the resident used oxygen, had been educated to remove and store oxygen prior to smoking, and had a wanderguard on her portable oxygen tank.

Following the fire, the care plan was updated on 1/29/26 with interventions such as daily room searches with the resident’s permission, safety checks, posting signs in Spanish about no smoking and oxygen being flammable, visualizing the room every shift to remove visible smoking materials, and using a wanderguard on the portable oxygen tank. However, between 1/29/26 and 2/2/26, the record did not include a comprehensive assessment or analysis supporting that 15-minute checks were appropriate or sufficient to prevent the resident from smoking, nor did the care plan provide instructions for staff if the resident was non-compliant with surrendering smoking materials. There was no documented assessment of the resident’s task-specific decisional capacity to safely engage in smoking while using oxygen, despite her dementia, moderate cognitive impairment on the MDS, and prior non-compliance on 12/24/25 and 1/29/26.

On 2/2/26, the resident told an interviewer she did not trust staff with her smoking materials and admitted refusing to give them up when asked. She produced a box of cigarettes and a lighter from her coat pocket while wearing a nasal cannula connected to oxygen at 2 LPM. A nursing assistant reported that the resident often refused to give up her smoking materials after returning from smoking outside and that staff did not always have time to check residents after smoking to ensure materials were turned in. Another nursing assistant and an RN stated the resident was non-compliant with smoking rules, hid smoking materials, and that residents sometimes shared supplies, but these refusals and hiding behaviors were not documented in the record between 12/23/25 and 2/2/26. An LPN showed that the drawer designated for smoking materials at the nurse’s station contained only office supplies and confirmed there was no log to track smoking supplies. The DON acknowledged that family brought in smoking materials without first bringing them to the nursing station and that it was difficult to take items from the resident. These observations and interviews demonstrated that the resident remained in possession of cigarettes and a lighter after the fire, that staff were aware of ongoing non-compliance and family involvement in supplying materials, and that there was no effective system or documentation to ensure smoking materials were secured as care planned, resulting in continued risk of fire.

Removal Plan

• Reviewed smoking policies with the medical director and ombudsman input.
• Developed and implemented a comprehensive system to prevent accidents, hazards, and fires related to smoking inside the facility, including a plan for residents who fail to comply with safe smoking practices.
• Reassessed R1's capacity to make safe decisions regarding smoking.
• Revised R1's care plan with individualized interventions.
• Identified residents with similar smoking risks and their level of compliance with facility smoking policy.
• Implemented individualized interventions for residents with similar smoking risks to prevent unsafe smoking.
• Re-educated residents on safe smoking policies and administered a knowledge check quiz.
• Educated all staff on smoking policies and administered a knowledge check quiz to demonstrate understanding.