Other·May 11, 2023

California Code of Regulations, Title 22, section 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. California Code of Regulations, Title 22, section 72507 - Smoking (b) The facility shall provide designated areas for smoking. Patients shall be permitted to smoke only in designated areas. The designated area shall be under the periodic observation of facility personnel or responsible adults. This does not preclude the designation of the patient rooms as smoking areas. Title 42 CFR 483.25(d) Accidents. The facility must ensure that - 483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and 483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. Based on observation, interview, and record review, it was determined that the facility failed to provide adequate supervision during smoking for Patient 1, in accordance with the facility policy and procedure. This failure resulted in Patient 1 sustaining a cigarette burn to her right elbow. On December 16, 2022, at 1:15 p.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a quality-of-care issue. On December 16, 2022, at 2:15 p.m., during a concurrent observation and interview with Patient 1, Patient 1 was observed smoking at the facility patio in her wheelchair, with no smoking apron. Patient 1 stated she smokes when she wants and not according to a schedule. She further stated smoking is not supervised. There were no smoking aprons, fire extinguisher, nor smoking blankets observed at the patio. In addition, there was no facility staff member providing supervision while the patient was smoking at the patio. On December 19, 2022, at 2:46 p.m., during an interview with Patient 1, she stated she burned herself while smoking alone at the facility. She further stated the cigarette burn required treatment from the facility staff. A review of Patient 1's Admission Record indicated the patient was admitted to the facility on December 7, 2021, with diagnoses which included neuropathy (damage to nerves outside of brain & spinal cord), schizophrenia (a serious mental disorder in which people interpret reality abnormally), and absence of both legs above the knee. A review of Patient 1's Change in Condition Evaluation, dated May 25, 2022, indicated, "Patient requested treatment nurse for skin assessment to left upper extremity... (Patient 1) stated her cigarette...fell on her arm and caused a small burn to her arm...Treatment orders received and carried out." The document indicated Patient 1 sustained a burn on her right lateral (outside) elbow. There was no documentation which indicated the degree of burn on Patient 1's right elbow. A review of Patient 1's care plan titled, "Patient is identified as a SMOKER", dated May 26, 2022, indicated interventions which included, "provide constant and/or frequent supervision when patient is smoking." A review of Patient 1's physician orders dated May 26, 2022, indicated, "Burn: right elbow: cleanse with NS (normal saline), pat dry, cover with DD (dry dressing) x (for the duration of) 14 days... every day shift." A review of Patient 1's Brief Interview for Mental Status (BIMS- an assessment of cognition status), dated November 28, 2022, indicated the patient had a score of 15 (no cognitive impairment). On December 19, 2022, at 2:30 p.m., during an interview with Certified Nursing Assistant (CNA) 1, she stated in the past the facility had a designated schedule for smoking to ensure a staff could supervise the patients while smoking. However, the facility now allows any patient to go outside independently, to smoke anytime they want. She further stated in the past the facility observed designated times to ensure a staff member could supervise the patients. On December 19, 2022, at 3:50 p.m., during an interview with Licensed Vocational Nurse (LVN) 1, he stated he was informed during the new employee orientation, that staff are to supervise smokers. On December 19, 2022, at 4 p.m., during an interview with the Registered Nurse Supervisor (RNS), she stated she was not aware if the facility has a designated smoking schedule, and she was not aware of the facility smoking practice. The RNS stated patients who smoke should be supervised by a staff. The RNS stated she ensures a CNA supervises the patient when a patient goes for a smoke. On December 19, 2022, at 4:18 p.m., during an interview with the Administrator (ADM), the ADM stated the following: 1. Patients who smoke get smoking assessments upon admission to the facility.; 2. The activities department are aware of the facility's smokers.; 3. Smokers requiring supervision are to be supervised by a CNA or other staff.; 4. The facility has a fire extinguisher, smoking blankets, and smokeless ashtrays.; and 5. Patients assessed as independent smokers can smoke without a staff member present. In a concurrent review of the facility smoking policy and procedures with the Administrator (ADM), The Administrator verified the facility smoking policy indicated all smoking is to be supervised and he stated the facility was not following the facility policy. A review of the facility's policy and procedure titled "Smoking Policy" revised October 24, 2017, indicated, "Patient smoking is only allowed during scheduled times. The designated supervised smoking schedule will be discussed with the patient...All smoking sessions will be supervised by Facility Staff members only... Patient who smoke shall wear a 'smoking apron'...if they are found not to be safe...Smoking apron, fire blanket and fire extinguishers will be available in the designated smoking area." Based on observation, interview, and record review, it was determined that the facility failed to provide adequate supervision during smoking for Patient 1, in accordance with the facility policy and procedure. This failure resulted in Patient 1 sustaining a cigarette burn to her right elbow. This violation had a direct or immediate relationship to the health, safety, or security of the patients.