Other·April 27, 2022

Health & Safety Code 1424 (d) (d) Class "A" violations are violations which the state department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. F689 483.25 (d) Accidents The facility must ensure that - 483.25 (d)(1) The resident environment remains as free of accident hazards as is possible; and 483.25 (d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 3/7/2022 at 8:00 a.m., an unannounced visit was conducted at the facility for a recertification survey. The facility failed to ensure patients were free of accidents and hazard for one of 24 sampled patients (Patient 40) when Patient 40 was not properly assessed for Smoking Safety Screen. These failures resulted in Patient 40 sustaining burns to face, neck, and chest after smoking unsupervised while on oxygen on 7/31/21. Review of Patient 40's clinical record indicated: When Patient 40 was admitted on 8/15/2020, he was on hospice and had diagnoses of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), chronic respiratory failure (condition in which not enough oxygen passes from your lungs and into your blood), depressive disorder (mood disorder which interferes with daily life), anxiety disorder (persistent feeling of worry and apprehension), schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder), and tobacco use. Review of Patient 40's Minimum Data Set (MDS, an assessment tool) dated 7/28/21, indicated he had a brief interview of mental status (BIMS, a structured cognitive test) scoring 13 (cognitively intact). Review of Patient 40's Safe Smoking Safety Screen, dated 9/30/2020, indicated and emphasized in red letterings Patients on Oxygen may not be independent smokers' but the form indicated with a check mark that Patient is a safe smoker and may smoke independently. Patient 40's Smoking Safety Screen was completed and signed by licensed vocational nurse A (LVN A). The intradisciplinary team (IDT, a coordinated group of experts from several different fields who work together toward a common business goal) members who attended the meeting were not listed on the space provided on the form. Review of Patient 40's Physician order, dated 9/28/2020, indicated decrease Oxygen to 2 L/M (liters per minute, oxygen flow rate) via NC (nasal cannula, a device used to deliver supplemental oxygen). Keep oxygen saturation (the percentage of oxygen in the blood) between 88/92 %. Review of Patient 40's SBAR (Situation, Background, Assessment, Recommendation) Physical Injury Report of Incident, effective date 7/31/21, indicated "pt was smoking with nasal cannula oxygen on, burned himself on up chest. sent pt to valley medical." Review of Patient 40's emergency department provider notes, dated 7/31/21, indicated status post oxygen tank explosion. Reports smoking cigarette while on oxygen. burns to face and neck with singed nasal hairs, singed beard hair with soot around mouth, small singe burns to tip of tongue, charred spots on tongue, soot across both palms, superficial burn of left forearm. Review of systems could not be obtained due to: Critically ill. States that his burns are painful. Fentanyl (a pain medication) injection 50 mcg (micrograms) Intravenous given 7/31/21 at 19:11. During an interview and observation with Patient 40 on 3/11/22 at 8:48 a.m., Patient 40 was in his room and on oxygen at four liters per minute via nasal cannula. Patient 40 stated he could not remember the date of the incident, but he can remember that he went out to smoke with oxygen on and burned his face, neck, and chest. During an interview with the director of nursing (DON) on 3/11/22 at 10:50 a.m., the DON stated Patient 40 was an independent smoker and no supervision was needed during the time of incident. During an interview and record review with the DON on 3/14/22 at 12:17 p.m., the DON confirmed Patient 40's Smoking Safety Screen, dated 9/30/2020, indicated and emphasized in red letterings Patients on Oxygen may not be independent smokers and the form indicated with a check mark that Patient is a safe smoker and may smoke independently. The DON confirmed Patient 40 was on oxygen at two L/M continuously starting 9/30/2020. The DON confirmed Patient 40 should not be independently smoking because Patient 40 was on oxygen. The DON confirmed Patient 40's Smoking Safety Screen, dated 9/30/2020, was an incorrect assessment. During an interview and record review with the DON on 3/15/22 at 11:05 a.m., the DON confirmed the IDT members attending in Patient 40's Smoking Safety Screen, dated 9/30/2020, was blank. The DON confirmed she could not find any supporting documents that IDT members attended. Review of facility's policy, "Smoking" revised 2/2018, indicated for those facilities that allow smoking, it is policy to monitor and evaluate patients for safety related to smoking. The IDT is responsible for evaluating safety risks and providing a safe designated smoking location. PROCEDURE, The IDT evaluates cognitive ability, judgement, mental dexterity and mobility, as well as the need for adaptive or safety equipment upon admission, with a significant change of condition/function, and annually for a patient expressing a desire to smoke. Staff will control the distribution of smoking material (cigarettes, cigars, tobacco, lighters). Patient assessed and deemed independent smokers may be provided a way to secure their own smoking materials in a locked drawer or container. Portable oxygen tanks and/or other O2 delivery systems are NEVER allowed in designated smoking areas, even if oxygen is turned off. The facility failed to ensure patients were free of accidents and hazard for one of 24 sampled patients (Patient 40) when Patient 40 was not properly assessed for Smoking Safety Screen. These failures resulted in Patient 40 sustaining burns to face, neck, and chest after smoking unsupervised with while on oxygen on 7/31/21. The facility's regulatory violations presented a substantial probability that serious physical harm to Patient 40 would result therefrom.