F0689

G

Unsecured Smoking Materials and In-Room Smoking Resulting in Resident Burns

Boardman, Ohio Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a hazard‑free environment by allowing residents to keep unsecured smoking materials and to smoke in undesignated areas, including inside resident rooms. One cognitively intact, wheelchair‑dependent resident with paraplegia, COPD, nicotine dependence, bipolar disorder, and chronic pain was assessed as an independent smoker and had signed the facility’s smoking acknowledgment form and resident smoking guidelines. These guidelines required that all smoking materials be kept by staff, that smoking occur only in designated areas, and that smoking materials be returned to staff when smoking was completed. The resident’s care plan identified him as a smoker with a goal to use nicotine products safely, with interventions including a smoking evaluation, education on designated smoking areas, education on the smoking policy, and provision of safe smoking devices if required.

Despite these policies and care plan interventions, the resident reported that he normally kept his smoking items on his person instead of giving them to staff to secure, even though he knew smoking materials were to be kept with staff. On the night of the incident, the resident was in bed, thought he was at home, lit a cigarette, and dropped the lit cigarette onto his lap. When he attempted to retrieve the cigarette, it came into contact with cologne that was in the bed, causing the cologne to ignite and burn his thigh and abdomen. Staff responding to the resident’s call light observed a haze, a chemical smell, and burn marks on his clothes, and noted a cologne bottle on the floor. The resident was transferred to the hospital, where he was diagnosed with partial thickness (second‑degree) burns to his right thigh and received topical antibiotic treatments.

Interviews with multiple staff members, including RNs, LPNs, and CNAs, confirmed that although the policy required smoking items to be secured by staff after residents finished smoking, at the time of the incident smoking items were not always returned to staff. Staff acknowledged that some residents kept smoking materials on their person or hidden in their rooms. Another resident stated she also kept her smoking items on her person and did not return them to staff until after she was educated by staff. The facility identified a total of 22 residents who smoked, and it was known at the time of the incident that some residents maintained smoking items on their person or in their rooms, contrary to the written smoking guidelines that limited smoking to designated areas and required staff to store smoking materials when not in use.