Health inspection·August 21, 2024

F 689 Title 42 CFR § 483.25 Quality of Care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: (d) Accidents. The facility must ensure that- (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents Title 22 CCR § 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved." On 4/26/24, an unannounced visit was conducted to investigate a facility reported incident regarding Resident 1 who smoked while on oxygen via nasal cannula, went up in flames and Resident 1 sustained a second degree (partial thickness burns involving the top two layers of the skin) burn to right and left cheeks. Resident 1 was an 85-year-old male, admitted on 6/6/21 with diagnoses of Dementia (memory loss), Respiratory Failure (breathing issues, dependent on oxygen), bipolar disorder (a mental illness that causes extreme mood swings that can make it difficult to complete daily tasks). Resident 1 is a smoker and using oxygen. Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards when one of 22 sampled residents of (Resident 1) was allowed to smoke unsupervised with oxygen applied. This resulted in Resident 1 sustaining second degree burns (partial thickness burns involving the top two layers of the skin) to the right and left cheeks. Findings: During a review of Resident 1's "Admission Record," (AR) the AR indicated, Resident 1 is an 85 year-old male, admitted on 6/6/21, with the following diagnoses: Dementia (is not a single disease, but a term for range of conditions that affect the brain's ability to think, remember, and function normally) with psychotic disturbances (refers to the mental state where person has trouble figuring out what is real, may have auditory, visual, hallucinations), bipolar disorder (mental illness characterized by extreme mood swings), schizophrenia (a serious mental disorder in which people interpret reality abnormally) and tobacco use. The AR indicated Resident 1 is his own responsible party. During a review of Resident 1's care plan with the focus on "[Resident 1] is a smoker, High risk for injury r/t [related to] smoking.," initiated 2/23/22, the care plan included the following interventions: "instruct resident about the facility policy on smoking: locations, times, safety concerns" initiated 2/23/22, "monitor oral hygiene" initiated 2/23/22, and the "[Resident 1] requires SUPERVISION while smoking" initiated 5/22/23. During a review of Resident 1's care plan with the focus on, "[Resident 1] Safety Regarding Lighter Use, the resident is non-compliant [resistant] with the facility 's policy and wants to keep a lighter and cigarette on him" initiated 11/11/23, the care plan included the following interventions: "discuss the consequences of fire hazards, including personal injury and community safety" Initiated 11/11/23, "document any incidents or near misses related to lighter use and adjust the care plan accordingly" initiated 11/11/23, "educate the resident on fire safety and the specific risks of carrying a lighter" initiated 11/11/23, and "provide alternative coping strategies if the lighter is used for non-smoking purposes . . ." initiated 11/11/23. During a review of Resident 1's "Order Details" (OD) dated 3/23/24, the OD indicated, "Oxygen @ [at] 3L [liters-unit of measure]/ [per] min[minute ]Via Nasal Cannula [thin plastic tube used to deliver oxygen to the nostrils] to keep O2 [oxygen] Sat [saturations- how well the lungs are working] at/[or]above 93% [normal range 95%-100%] DX [diagnosis] SOB [shortness of breath] every shift". During a review of Resident 1's "Smoking Safety," (SS) evaluation dated 3/25/24, the SS indicated, "Balance problems while sitting or standing. . . Follows the facility ' s policy on location and time of smoking . . . [Resident 1] has history of smoking (no documentation regarding Resident 1 ' s ability to hold, light, and extinguish cigarette or the type of supervision Resident 1 needed)". During a review of Resident 1's "Minimum Data Set," (MDS - an assessment tool) dated 3/30/24, the MDS indicated, Resident 1' s Brief Interview for Mental Status score (BIMS score - an assessment to determine a resident ' s cognitive [term for mental processes] ability) score of 11 (a score of 8 to 12 indicates moderately impaired cognition). During a review of Resident 1 ' s "Medication Administration Record," (MAR) dated 4/1/24 to 4/30/24, the MAR indicated Resident 1 received "Oxygen @ 3L/min Via Nasal Cannula to keep O2 Sat at/above 93% DX SOB [Shortness of breath] every shift -Start Date- 3/23/24 2300 . . . [required to check each shift, not documented each time oxygen is applied]" During a review of Resident 1 ' s "Progress Notes," (PN) dated 4/24/24 at 11:15 a.m., the PN indicated, "[Resident 1] was found [sic] burns to the face while outside in the smoking area." During a review of the "SBAR Communication Form [Method of documenting the condition of a patient to include Situation, Background, Assessment, Recommendation]" dated 4/24/24 the SBAR Communication Form indicated, on 4/24/24 the resident sustained a skin wound or ulcer (open sore). The SBAR Communication Form indicated the resident sustained burns to the face and under the section titled "Pain Evaluation", the documentation indicated the resident is experiencing pain due to "Burns to face. . ." During a review of Resident 1 ' s "Weekly Skin/Wound Assessment," (WSWA) dated 4/24/24 at 12:25 p.m., the WSWA indicated Resident 1 sustained burns to the following areas: right cheek had popped blisters measuring 3.5 centimeters (cm - unit of measurement) in length and 2 cm in width; left cheek had a popped blister measuring 1.5 cm in length and 1.5 cm in width. The WSWA indicated, "[Resident 1] has dark colored facial hair from soot/smoke to mustache, beard, right eyebrow, and eyelashes." During a concurrent observation and interview on 4/26/24 at 10:26 a.m. with Resident 1, in Resident 1's room, Resident 1 was lying in bed. Resident 1's face had circular redness with white colored substance noted on the right cheek approximately the size of a soda can, the skin under Resident 1's nose was black (possible facial hair) with the white substance over the top of the skin, the left cheek had a quarter sized patch of red skin with white substance noted on top. Resident 1 stated, "I started to light my cigarette and I just caught on fire [referring to the day of the incident on 4/24/24]." Resident 1 stated no one from the facility has talked to him about oxygen use on the smoking patio. Resident 1 stated "I don't usually wear oxygen." Resident 1 stated he had a Certified Occupational Therapy Assistant (COTA 1) take him out to the smoking patio [on the day of the incident]. He stated, "I told him [COTA 1] I want to go outside so I could smoke." Resident 1 stated when he went to the smoking patio there were no staff members present only other residents. Resident 1 stated occasionally there was a staff member on the smoking patio but usually it is only residents. During an interview on 4/26/24 at 10:48 a.m. with Certified Nursing Assistant (CNA 1), CNA I stated she has been assigned to care for Resident 1 and is familiar with his care needs. CNA 1 stated Resident 1 smokes independently and does not require assistance with holding or lighting his cigarette, she stated Resident 1 keeps his cigarettes and lighter in his room. CNA 1 stated he stores his cigarettes and lighter in his nightstand and has found lighters in his closet. CNA 1 stated she has taken the resident out to the smoking patio area in the past. CNA 1 stated, when she takes the resident out to the smoking patio to smoke, "If I don't see anyone [staff member on the smoking patio] I will just wait there with him." During an interview on 4/26/24 at 1:37 p.m. with Director of Nursing (DON), DON stated Central Supply (CS) was supposed to go to the smoking patio at 10 a.m. DON confirmed CS did not go to the smoking patio on 4/24/24. DON stated there was no staff in the smoking patio when Resident 1 sustained burns to the face. During a review of Resident 2' s "MDS" dated 3/25/24, the MDS indicated, Resident 2's BIMS score was 15 (13 to 15 points indicates cognitive intactness). During an interview on 4/29/24 at 2:07 p.m. with Resident 2, Resident 2 stated she was out on the smoking patio on 4/24/24. Resident 2 stated when she went outside to the smoking patio Resident 1 was already in the middle of the courtyard. Resident 2 stated Resident 1 had his oxygen on. Resident 2 stated, "I told him [Resident 1] you cannot be smoking with oxygen on [and] he said, 'No, no [COTA 1] turned it off. ' " Resident 2 stated she was going to check to make sure his oxygen tank was off and just as she was next to Resident 1, she saw Resident 1 ' s face go up in flames. Resident 2 stated she grabbed the nasal cannula and threw it on the ground and then patted Resident 1 ' s face to put the fire out. Resident 2 then stomped on the nasal canula because it was still on fire. During an interview on 4/29/24 at 3 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated she responded when COTA 2 came running in on the date of the incident. LVN 1 stated COTA 2 informed her residents need a nurse outside on the smoking patio. LVN 1 stated, "I went running and looked around, I noticed [Resident 1 ' s] face was black, and [Resident 2] was calling me over, the nasal cannula was black, and on the ground, it was not on fire." During an interview on 4/29/24 at 3:08 p.m. with COTA 2, COTA 2 stated she was crossing through the outside courtyard going to activities department, when she heard "Help, help". COTA 2 stated she only saw two residents on the smoking patio. COTA 2 stated she turned around and ran to get a nurse. COTA 2 stated she took LVN 1 to where the two residents were outside on the smoking patio. During a concurrent interview and record review on 4/29/24 at 3:23 p.m. with Director of Nursing (DON), DON reviewed Resident 1's "OD," dated 3/23/24. DON stated Resident 1 did have an order for oxygen dated 3/23/24. DON reviewed Resident 1' s care plan initiated on 2/23/23 with the focus on, "[Resident 1] is a smoker. High risk for injury r/t smoking." DON confirmed no interventions for oxygen were developed prior to the Resident 1 smoking with oxygen on and sustaining burns to his face. DON confirmed one of Resident 1 ' s care plan interventions initiated on 5/22/23 indicated Resident 1 needed supervision while smoking. DON confirmed Resident 1 was smoking unsupervised with oxygen on when his face caught on fire resulting in burns to Resident 1' s face. DON stated Resident 1's face was observed to be black in color but then the face developed blisters, DON described Resident 1's burn as second-degree burn. During a concurrent interview and record review on 5/30/24 12:18 p.m. with DON, Resident 1's care plan was reviewed with the focus on, "[Resident 1] Safety Regarding Lighter Use, the resident is non-complainant with the facility ' s policy and wants to keep a lighter and cigarette on him.," initiated 11/11/23, the care plan included the following interventions: "discuss the consequences of fire hazards, including personal injury and community safety" initiated 11/11/23, "document any incidents or near misses related to lighter use and adjust the care plan accordingly" initiated 11/11/23, "educate the resident on fire safety and the specific risks of carrying a lighter" initiated 11/11/23, and "provide alternative coping strategies if the lighter is used for non-smoking purposes . . ." initiated 11/11/23. Requested the policy and procedure (P&P) regarding lighter use. DON stated the facility does not have a P&P for safe lighter storage. DON stated safe lighter storage now is a lock box, but prior to the incident the alert and oriented residents were allowed to keep their lighter and cigarettes. DON reviewed Resident 1's medical record and was unable to provide evidence the interdisciplinary team (IDT) developed an individualized plan of care for safe storage and use of smoking materials for Resident 1. DON was unable to provide evidence Resident 1 was educated regarding the risk of smoking and smoking safety measures. During a review of facility policy and procedure (P&P) titled, "Resident Safety," revised 4/15/21, the P&P indicated, "Purpose To provide a safe and hazard free environment Policy Resident will be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstance that pose a risk for the safety and well-being of the Resident. Procedure I. During the comprehensive assessment period the interdisciplinary team (IDT) members will assess the Resident ' s safety (e.g., fall, smoking, . . .) as well as any other Resident specific safety risks II. During the quarterly care plan review, when there is a change in condition or if an accident or incident occurs that involves the Resident's safety, the Resident's risk will be re-evaluated III. After a risk evaluation is completed, a Resident -centered care plan will be developed to mitigate safety risk factors IV. The IDT will establish a person -centered observation or monitoring system for the resident to address the identified risk factors identified." During a review of facility P&P titled, "Smoking Residents," effective date 8/18/23, the P&P indicated, "2. Smoking by residents is allowed outside the facility in designated, marked smoking areas with the following safety measures readily available: . . . 4. Oxygen use is prohibited in smoking areas. . . .6. Using the Resident Smoking Assessment, the Licensed Nurse will assess residents who express a desire to smoke, upon admission, quarterly, annually and upon significant change of condition, and present it to the Interdisciplinary Team (IDT)for review. . .. 8. The IDT will develop an individualized plan of care for safe storage, use of smoking materials, assistance and/or required supervision, for residents who smoke. 9. The resident and/or Responsible Party will be educated regarding the risk of smoking and smoking safety measures recommended by the IDT. This document will be in the resident ' s clinical record. In violation of the Code of Federal Regulations §483.25(d)(1)(2), the facility failed to ensure that the resident environment remains as free from accident hazards as is possible; and each resident receives adequate supervision. The Department determined that the facility failed to ensure the environment was free of accident hazards for Resident 1, when Resident 1 was allowed to smoke unsupervised with oxygen applied. This resulted in Resident 1 sustaining second degree burns (partial thickness burns involving the top two layers of the skin) to the right and left cheeks. This violation presented either imminent danger that serious harm would result or a substantial probability that death or serious physical harm would result and constitutes to "A" citation.