**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 08/16/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Resident #2, who had a known history of unsafe smoking did not smoke in their room and catch themselves on fire. Resident #2 was admitted to the facility on [DATE] with diagnoses which included dementia. Resident #2 was admitted to the hospital on [DATE] with second and third degree burns. On 08/16/24 at 11:45 a.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation related to for Res #2 smoking in their room and catching themselves on fire. On 08/16/24 at 11:47 a.m., the administrator was notified of the IJ situation. On 08/19/24 at 9:10 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Plan of Removal (Accident Hazards Related to Smoking Without Supervision) Tag Cited: F-689 (Accident Hazards Related to Smoking Without Supervision) Preparation and/or execution of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur or recur. The facility asserts that the likelihood of serious harm no longer exists as of August 16, 20247 at 4:30 p.m. Issue Cited: The facility failed to supervise Resident #2, who had a known history of unsafe smoking, to ensure they did not have access to smoking materials or were supervised while smoking. As a result, Resident #2 caught on fire while smoking a lit cigarette in their room. The resident's daughter reported that Resident #2 is currently being treated at hospital for second and third degree burns to the abdomen and back. Identification of Residents Affected or Likely to be Affected: ( Completion Date 08/12/2024) a. Resident #2 was not in the building at the time of this survey b. [Resident #3] c. [Resident #1] d. [Resident #4] e. [Resident #5] f. [Resident #6] g. [Resident #7] Actions to Prevent Occurrence Recurrence: 1. Social Services conducted a 100% audit of residents who smoke on the Smoking Safety Screen and updated resident's screen to reflect the current status. 8-12-24 2. Social Services conducted a 100% audit on BIMS assessments for residents who smoke and updated them to reflect the current status. 8-12-24 3. Wound Care nurse conducted a 100% skin sweep of all residents who smoke and updated the skin assessment to reflect the current status. 8-12-24 4. The Housekeeping Supervisor conducted an inspection of resident clothing for all residents who smoke to identify need for assessment or supervision. 8-12-24 5. The Maintenance Director inspected the facility grounds for smoking materials, smoking aprons, ashtrays, and fire extinguishers. 8-12-24 6. The MDS Coordinator conducted a 100% audit on residents' care plans and updated them to reflect the current status. 8-12-24 7. The Administrator attended the Resident Council to review the smoking policy with the residents. 8-13-24 8. The Housekeeping Supervisor and Social Services conducted a room sweep of residents who are supervised smokers for lighters and smoking materials. 8-12-24 9. The DON and the Administrator conducted a smoking in-service for all employees, which was completed on August 16, 2024, at 4:30 PM. Ongoing education will be provided to new staff and as needed. 10. The Administrator conducted QAPI to discuss the smoking policy and procedure, completed on August 15, 2024. 11. Delegated staff are assigned specific smoking times according to the smoking schedule for supervised smokers, 8-12-24 12. The DON and/or designee will review smoking safety screening for each admission during clinical meeting and implement the appropriate interventions. 8-12-24 13. Admissions and Social Service will review the smoking times and policy with each new admission. 8-12-24. The immediacy was lifted, effective 08/16/24 at 4:30 p.m., when all components of the plan of removal had been completed. The deficiency remained at a level of actual harm. Based on record review, and interview, the facility failed to ensure a resident at risk for unsafe smoking did not have access to smoking materials and was supervised during smoking for one (#2) of three sampled residents reviewed for safe smoking. The administrator identified six residents who required supervision with smoking and 17 residents who smoked independently. Findings: The facility's undated, Resident Smoking policy, documented it was the policy of the facility to provide a safe and healthy environment for residents, visitors, and employees, included safety as related to smoking, and safety protections applied to smoking and non-smoking residents. The policy documented all residents and family member would be notified of the policy during the admission process and as needed, any resident who was deemed safe to smoke, with or without supervision, would be allowed to smoke in designated smoking areas in accordance with their care plan, all safe smoking measures would be documented on the resident's care plan, supervision would be provided as indicated on each resident's care plan, smoking materials of residents requiring supervision with smoking would be maintained by nursing staff or designee. Resident #2 had diagnoses which included unspecified dementia, psychotic disturbance, mood disturbance, and acquired absence of right leg below the knee. Resident #2's baseline care plan, dated 07/18/24, documented they required one person physical assistance with transfers, was alert, cognitively impaired, had a diagnosis of dementia, resident smoked supervised. The care plan also documented the resident's family provided cigarettes for Resident #2 but would like them locked up for the nurse to ration out or the resident would smoke them all. Resident #2's Smoking care plan, dated 07/19/24, read in part, [Resident #2] is a smoker. [Resident #2] has a history of being non compliant with facility smoking policies. The resident will not suffer injury from unsafe smoking practices through the review date. Interventions Instruct resident about smoking risks and hazards and about smoking cessation aids available. Date Initiated on 07/19/2024 Instruct resident about the facility policy on smoking: locations, times, safety concerns. Date Initiated: 07/19/2024 Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Date Initiated: 07/19/2024 The resident requires a smoking apron while smoking. Date Initiated: 07/19/24 The resident requires SUPERVISION while smoking. Date Initiated: 07/19/2024 The resident's smoking supplies are stored Hall 200 nurse cart. Date Initiated 07/19/2024 Revision 08/12/2024. A nurse's progress note, dated 07/23/24 at 5:26 p.m., documented the nurse observed Resident #2 in the smoking area holding their cigarette resident stopped looking at where the cigarette was and almost burned their leg, witnessed it again and placed a smoking apron on the resident, the resident refused the apron shortly after it was placed on the resident and stated, I can't wear this, it swallows me. The note documented the nurse notified the activities director that the resident did not use the big aprons and they stated they would follow up on it in the morning. An admission assessment, dated 07/24/24, documented Resident #2's cognition was intact, had no behaviors of rejection of care, wandering, physical or verbal aggression, had limited range of motion lower extremity and utilized a wheelchair for ambulation, needed supervision or touching assistance for transfers to and from bed to chair. A nurse's progress note, dated 07/29/24 at 4:36 p.m., documented Resident #2 had fallen outside in smoking area, nurse assessed the resident and no new injuries were noted, upon questioning Resident #2, they stated that they were bending over to pick up a cigarette butt off of the ground to smoke and fell over, two residents who were outside witnessed the incident and stated the resident did not hit their head. A nurse's progress note, dated 07/30/24 at 3:54 p.m., documented Resident #2 continued to go outside and smoke without staff supervision, nursing staff giving frequent reminders on safety and requesting assistance as needed. A nurse's progress note, dated 07/31/24 at 5:02 p.m., documented Resident #2 continued to propel self in wheelchair to go out and smoke without supervision, Resident #2 was verbally aggressive, demanding cigarettes from other residents and remains non-compliant with safe smoking protocols, nursing staff giving frequent reminders on safety and requesting assistance as needed. A nurse's progress note, dated 07/31/24 at 6:16 p.m., documented Resident #2 was self propelling themselves outside to try to smoke unsupervised and resisted all attempts to redirect. A nurse's progress note, dated 08/01/24 at 3:53 p.m., documented Resident #2 was seen by staff and other residents this morning falling asleep while in the smoking area with a lit cigarette in their hand, staff stated they picked up the cigarette out of Resident #2's lap but the resident's clothing was singed, the nurses assessed the resident and saw no new concerns to skin at the time. The progress note also documented the DON stated Resident #2 should go with staff and resident was notified that they would need to begin smoking with staff and the only time they could go smoke was with staff and they asked Resident #2 if they could have their lighter, Resident #2 handed over their lighter to the staff. A document titled, Incident Report Form, dated 08/11/24, read in part, Initial .Certain Injuries .investigation initiated .Resident was seen headed out to the smoking area by on duty nurse. Nurse went to another hall, upon return [they] heard resident yelling out for help. Resident was found in room with a lit cigarette and clothing on fire. Nurse used blanket to put fire out. Resident had burns and was sent out to ER . An ambulance report, dated 08/11/24, documented upon arrival Resident #2 was found sitting in their wheelchair with burns. Nurse had advised that she had been passing dinner trays and heard the resident yelling help me, the nurse went to the room and found Resident #2's torso to be on fire, the resident's shirt was noted to be on the floor and burned. The report also documented the wheelchair had areas where it had melted, the resident's brief and pants were also melted on the left side waist band. The nurse reported they did not know how the resident had gotten a lighter into their room. A document titled, ED to Hospital Admission-Burn ICU, dated 08/11/24, read in part, impression: Acute pain .Burn involving 10-19 % of body surface, third degree burn less than 10% .14% [total body surface area] flame burn Third degree burn chest .Left upper extremity .Plan for debridement and grafting on 8/13 . The admission assessment also read, .Full thickness burn of chest wall .Full thickness burn of multiple sites of left upper extremity .17% [total body surface area] flame burn . A document titled History and Physical, dated 08/11/24, documented Patient initially sustained burn injuries on 08/11/24 after being found by nursing facility staff at 6:14 p.m., the nursing staff heard the patient crying out in their room and found them on fire sitting in their wheelchair. The patient sustained burn injuries to the left flank, torso, and left upper extremities. The fire was put out by the nursing staff and EMS was notified. Patient was brought to the emergency department and admitted with a diagnosis of 17% total body surface area flame burn. Due to the patient's dementia, it is unclear the event leading up to the incident, but patient reportedly states they were attempting to light a cigarette. A document titled, ED Provider Note, dated 08/11/24, read in part, Left side of the patient's head has burn marks to the hair without burns to the face itself .Left upper inner arm noted to have a PICC in place .PICC tubing does have evidence of melting noted . On 08/15/24 at 4:02 p.m., Resident #11 stated they kept their cigarettes and lighter with them. Resident #11 stated they were told by staff another resident tried to burn themselves up by smoking in their room. On 08/16/24 at 6:41 a.m., Resident #10 was observed in the smoking area. Resident #10 was asked if other residents had requested cigarettes or a lighter from them. They stated yes, a couple of times. Resident #10 stated the staff had told them not give other residents cigarettes or lighter. On 08/16/24 at 6:45 a.m., Resident #9 was observed in the smoking area. Resident #9 stated other residents had asked them for cigarettes and they had given them a cigarette. On 08/16/24 at 7:11 a.m., Resident #8 was observed in the smoking area. Resident #8 stated they were allowed to smoke when they wanted and had their smoking material on them. Resident #8 stated the staff brought some residents out and assisted them with putting on an apron and stayed with them while they had a cigarette. Resident #8 stated at times the staff would leave the residents who needed assistance and go in and get something but the resident would not have a lit cigarette and they would come right back out. Resident #8 was asked if any residents had asked them for cigarettes and/or lighter. They stated yes, and they would tell them no. Resident #8 stated a CNA had told them a resident had burned themselves smoking in their room. On 08/16/24 at 7:44 a.m., CNA #5 stated they had been working the day Resident #2 caught on fire. They stated it had happened during shift change and they were not aware how it had happened and they had not taken Resident #2 out to smoke. On 08/16/24 at 8:06 a.m., CNA #4 stated Resident #2 had tried to smoke in the building before 08/11/24. CNA #4 stated the facility did not have interventions in place to ensure the resident did not have a cigarette or lighter when they came back in from the smoking area. They stated the nurses kept Resident #2's cigarettes and lighter on the nurse's cart. CNA #4 stated on one occasion when they smelled smoke they had checked Resident #2's room and notified the charge nurse, they stated they did not find anything and kept a close eye on the resident that day. CNA #4 was asked if they had an in-service related to the smoking incident since it had happened. They stated, No. CNA #4 was asked what interventions had been put in place to prevent the resident from going out to smoke unsupervised or smoking in the building. They stated they would put him up by the nurses' station. On 08/16/24 at 8:17 a.m., LPN #3 stated they went in Resident #2's room after the fire had been put out and the resident had a cigarette in their hand. LPN #3 stated Resident #2's shirt was burnt, their abdomen, left side flank/back area, and upper forearm was burned and the resident's hair and eyebrows were singed. LPN #3 was asked how the resident had gotten the cigarette and lighter. They stated the cigarette was short and they did not know how the resident had gotten it. LPN #3 stated Resident #2 would sit by the nurses' station and ask for cigarettes. LPN #3 stated Resident #2 required supervision when they smoked. On 08/16/24 at 8:30 a.m., CNA #2 stated they had just gotten to work on 08/11/24 when the incident had happened with Resident #2 setting themselves on fire. They stated they did not know how the resident got the cigarette or lighter. CNA #2 stated LPN #1 had found a lighter in Resident #2's room but did not say how the resident got the lighter. On 08/16/24 at 8:42 a.m., LPN #4 stated they had smelled smoke and found a cigarette butt in Resident #2's pocket. LPN #4 was what interventions were in place to prevent Resident #2 from smoking in the building. They stated they would take the resident out to smoke extra times because the resident became fixated on smoking and was hard to redirect. LPN #4 stated Resident #2 would follow them down the hall and ask to smoke. LPN #4 stated when the resident was admitted all of their clothes had what looked like cigarette burn holes in them. LPN #4 stated Resident #2 was not safe to smoke unsupervised. LPN #4 stated they had found a cigarette on Resident #2 twice in one day. On 08/16/24 at 9:31 a.m., Resident #2's family member stated they were not there when the resident caught themselves on fire and did not know how the resident got the cigarette or lighter. They stated Resident #2 required supervision while smoking. Resident #2's family member stated they thought the resident knew the smoking rules but the resident had dementia and had to be reminded they were at the facility because of their foot. Resident #2's family member stated the resident was in the burn unit with third degree burns to their back, second degree burns to the chest. Resident #2's family member stated they had not given the resident the cigarettes or lighter. They stated they had given the cigarette and lighter to the nurses. On 08/16/24 at 9:51 a.m., the administrator was asked what occurred when Resident #2 caught themselves on fire. The administrator stated based on interviews and phone calls the nurse reported Resident #2 was injured in a fire. The resident was outside being supervised, came back to their room and the nurse heard the resident yelling for help, the nurse saw the resident on fire, and put the fire out with a blanket. The administrator stated they did not know who had been supervising Resident #2 while they had been smoking. The administrator stated they had not interviewed all the staff who had worked that day. The administrator stated the staff they had talked to did not say who had supervised Resident #2 while they were smoking. The administrator stated the staff reported the resident was non-compliant with the smoking policy. The administrator was asked what interventions had been put in place for the resident to prevent smoking accidents. They stated they had told the other residents not to give out cigarettes or lighters to other residents, staff was to monitor Resident #2 while smoking, attempted care plan meeting with family and resident, and smoking cessation medication. The administrator stated Resident #2 had smoked approximately an hour before they had caught themselves on fire but did not know who had supervised the resident. An email statement from the former DON, dated 08/16/24 at 10:06 a.m., read in part,[Resident #2] was determined to be a supervised smoker upon admission. [Resident #2] was non-compliant with care and with smoking policy. Many educational conversations were had with the resident [related to] following the smoking policy, allowing staff to assist to smoke, and wearing smoking apron. Resident refused to wear smoking apron, continuously demanded cigarettes from other residents, and would go outside without alerting staff or asking for help. Staff educated all other residents not give cigarettes to resident. Staff obtained orders for medication to assist with smoking cessation. Facility attempted to set up a care plan meeting with [family] and resident but both declined to come to meeting. [Family] was informed of all incidents with resident and stated that these were not new behaviors . On 08/16/24 at 10:48 a.m., the administrator stated they would have to look in the computer to see when the resident required smoking supervision. The administrator stated the DON usually answered these questions however the current DON was new and was not here when the incident occurred. The administrator was asked if anyone had followed up to get Resident #2 a smaller smoking apron as stated in progress note on 07/23/24. They stated they would have to check. The administrator was asked how the resident had fallen in the smoking area trying to pick up a cigarette butt if they were being supervised. They stated the staff may not have gotten to the resident in time to prevent them from falling. The administrator was asked what interventions were put in place to prevent Resident #2 from going out to smoke unsupervised besides redirecting. They stated they would have to check. The administrator was asked if there had been any new interventions put in place on 07/31/24 when the resident was asking other residents for cigarettes. They stated they would have to look. The administrator was asked how Resident #2's clothes became singed on 08/01/24 if the resident was being supervised. The administrator stated they would have to check. On 08/16/24 at 1:12 p.m., CNA #6 stated they had received an in-service today 08/16/24 right before lunch related to residents smoking. The CNA stated this was the first in-service they had received this week related to residents smoking. On 08/16/24 at 1:13 p.m., CNA #4 stated they had received an in-service related to smoking around 12:30 p.m. CNA #4 was asked if they had received any other in-services this week related to residents smoking prior to today. They stated, No. On 08/16/24 at 1:28 p.m., housekeeper #1 stated they had received an in-service related to residents smoking today 08/16/24. They stated this was the first in-service related to resident smoking they had received this week. On 08/16/24 at 1:40 p.m., CMA #1 stated they had not received an in-service this week. They stated they had last worked on Sunday 08/11/24.