**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 01/11/23 at 10:20 a.m., the Oklahoma State Department of Health (OSDH) confirmed the existence of an immediate jeopardy related to failing to send a resident who sustained a burn to the hospital. The facility failed to ensure the resident was provided emergency medical evaluation and/or treatment after the resident sustained a serious burn and failed to document assessment and monitoring of the injury. On 12/26/22 at 11:10 p.m. Resident #40 was found by staff with burns to their scalp, hair, face, bilateral ears, and left hand, while wearing oxygen. Resident #40 was not sent to the hospital for evaluation and/or treatment of the burns and was not assessed by the physician until 12/30/22 (Four days after the burn injury occurred.), There was no documentation of the degree, or size of the burns and no documentation of the residents lung sounds or oxygen saturation after the incident. On 01/11/23 at 10:47 a.m., the Administrator was informed of the existence of the immediate jeopardy. A request was made for an acceptable plan to remove the immediacy. On 01/11/23 at 3:36 p.m., the plan of removal was accepted by the OSDH. The plan of removal was as follows: Plan of Removal (3) 01/11/2023 1. Licensed nurses will be in-serviced on the policy regarding basic first aid, using nursing judgement for the need for emergency medical evaluation and treatment, and assessing a resident after a serious incident. This education will be completed on 01/11/23 by 6:00 pm by the Director of Nurses, Assistant Director of Nursing and/or Administrator. 2. PCP's and medical director for the facility will be in-serviced regarding evaluation of a resident with a serious injury within 24 hours of the occurrence. Should the resident require immediate evaluation, they will be sent to the emergency room. This education will be completed by 01/11/23 at 5:00 pm. 3. A record review will be completed on residents with serious injury in the last 3 months to ensure that a proper assessment was completed and documented by 01/11/23 at 6:00 pm. 4. Nursing documentation (to include vital signs, pulse oximetry and lung assessment if indicated) will be reviewed by the IDT team the following business day on serious injuries to ensure that appropriate care was provided. 5. All CNA's, CMA's Dietary, Housekeeping, Laundry, Maintenance Staff will be educated on procedure to follow in case of serious injury. Education will be provided by DON, ADON, Administrator, MDS RN and Social Services. 6. In case of employee on leave of absence or vacation, they will be educated before their next shift. On 01/12/23 from 8:15 a.m. to 11:00 a.m., interviews were conducted with staff regarding education and in-service information pertaining to the immediate jeopardy plan of removal. The staff stated they had been in-serviced and were able to verbalize understanding of the information provided in the in-service pertaining to the plan of removal. Random facility incident reports were reviewed to verify staff audits for resident assessment and treatment after an injury. On 01/12/23 at 11:23 a.m., the Administrator was notified the immediacy was lifted effective 01/11/23 at 5:00 p.m. and the deficiency remained at a level of harm with a limited number of residents affected. Based on record review, observation, and interview, the facility failed to assess, monitor, and intervene for a resident who sustained burns for one (#40) of two sampled residents reviewed for smoking. Resident #40 sustained multiple burns while smoking in their room. The Administrator identified two residents who smoked and had an order for oxygen and nine additional residents who smoked. Findings: The Change in a Resident's Condition or Status policy, revised February 2021, read in part, .Our facility promptly notifies .his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's attending physician or physician on call when there has been a/an .accident or incident involving the resident . Resident #40 had diagnoses which included dyspnea, vascular dementia, and heart failure. A Physician's Order, dated 12/14/22, documented O2 at 2L as needed for shortness of breath or decreased oxygen saturation. An annual resident assessment, dated 12/24/22, documented Resident #40's cognition was moderately impaired, independent with transfers and walking with walker, used tobacco and received oxygen. Resident #40's Care Plan, initiated 12/26/22, read in parts . [resident] has increased shortness of breath .O2 @ 2L/M via N/C RN .[Resident] smokes several times daily with supervision . An incident report dated 12/26/22 at 11:15 p.m., read in parts, .resident lying on floor, face down, by recliner .trying to locate where smoke smell was .observed brown material on the floor .hair was burnt, hair was falling out in melted clumps .superficial burn to right upper scalp, other burns observed .applying first aid .type of injury . burn .injury location .Top of scalp .left hand (palm) .Face .Right ear .Left ear . A Progress note dated 12/27/22 at 3:33 a.m., read in parts, .observed resident lying on the floor face down in front of recliner .smelled smoke .observed brown colored matter, on the floor around resident's head .realized that hair was burnt, and falling out in melted clumps .has what appears to be superficial burn on right upper scalp, blisters on 2,3,4,5, digits of left hand, burn mark from O2 tubing to right cheek, both ears burnt, O2 tubing was burnt an changed, contacted ADON who commented they would evaluate resident in morning .fax to PCP . No fax document found in the clinical record. There was no documentation found in Resident #40's clinical record of measurements, type of tissue, exudate or lung sounds. A Physician's Order dated 12/27/22 documented Silvadine cream to burns and to fingers with Keflex bid. A Progress note dated 12/27/22 at 10:47 a.m., read in parts, .Spoke to PCP new orders for Silvadine cream to be applied to burns .bid . A Skin Observation Tool dated 12/28/22, read in part, .Patient has new burns in place orders are in place. no other issues are noted. A Progress Note dated 12/30/22 documented the Medical Director/Attending Physician was in to see resident and that the resident continued with three pitting edema and shortness of breath with exertion with use of oxygen at nocturnal. There was not documentation from the physician of the description of the burns. Resident #40's Care Plan, .revised on: 01/01/23 .[resident] has actual impairment to skin integrity D/T BURN of the left hand and ears .Weekly skin assessments treatments documentation to include measurement of each area of skin injury type of tissue healing and exudate and any other notable changes or observations . A Skin Observation Tool dated 01/04/23, read in part, .wound care orders in place to burns on ears and hands. Facial burn healed . A physician note documented on a prescription pad, dated 01/10/23 with Resident #40 name on it, signed by the Medical Director, who was also the attending physician, documented, The nursing home called me just after pt getting burned- I saw this patient on [DATE]th Evaluated this pt. burn I also ordered [resident] Lasix & K. A Skin Observation Tool dated 01/11/23, read in part, .Right ear burn Left hand (palm) burn Left hand (back) burn .wound care orders in place . There was no documentation found of description, stage, or measurements of burns on the skin observation tools dated 12/28/22, 01/04/23, and 01/11/23, or in the clinical record. On 01/09/23 at 2:21 p.m., Resident #40 was asked if they smoked. The Resident's roommate stated the resident caught [their] hair on fire. Resident #40 was asked to explain. They stated once put the cigarette in my mouth then light the cigarette, then boom. I had oxygen on. The Resident was asked if they wore the oxygen when they smoke. They stated not normally. Resident #40 stated they were not suppose to smoke in the room. The Resident stated they caught their hair on fire and it had to be cut off. Resident #40 was asked why they were smoking in their room. They stated because they did not get to finish their cigarette when they were outside. Resident #40 stated they were not sent to the hospital after they were burned. Resident #40 was asked if they had any injuries other than their hair being burned. They stated, Yes. The resident stated they burned their left hand, right ear, and part of their scalp. Scabs were observed to the resident's right ear and bandage to left hand. On 01/09/23 at 4:10 p.m., CNA # 3 was asked about the incident with Resident #40. They stated while they were assisting another resident they heard the nurse asking Resident #40 if they had fallen. CNA #3 stated they asked CNA #2 to go check on Resident #40. CNA #3 stated they heard CNA #2 yell for assistance. CNA #3 stated by the time they were halfway down the hall, the ceiling light was on in the room and they could see smoke coming down the hallway. When they got there, there was so much smoke in the room they could hardly see. They stated the resident was face down on the floor with their coat, gloves and may have had her hat on but not sure. They stated there was something that looked like black coffee grounds on the floor. CNA #3 stated they touched the resident on the back of their head and realized it was the resident's hair on the floor. CNA #3 stated Resident #40 requested assistance to sit up. CNA #3 stated Resident #40 still had the O2 on their face and over their ears. They stated Resident #40 still had the cigarette in their hand. They stated the window and the outside door was opened to air out the smoke. CNA #3 stated they took the oxygen off of the resident and the resident had a red place on their right cheek, right ear, the side of the ear closest to the oxygen looked the worst. CNA #3 stated the resident's head was really red and hair was in clumps to their head on one side. They stated that through all that they did not know what to do. CNA #3 stated they were all upset because they were not sending the resident out. CNA #3 was asked why the resident was not sent out to the hospital. They stated they were told they would look at the resident in the morning to determine weather or not to send them out. CNA #3 further stated they heard the resident was not sent out because the resident did not show signs of pain. CNA #3 stated they all looked at each other and thought this was wrong and felt the resident should have gone to the hospital, and did not feel they could call 911 after having been told they will check on the resident in the morning. CNA #3 stated It bothered them that the nurse could not have say so to send a resident out to the hospital. They stated they heard a nurse sent a resident out before and got in trouble because administration felt the resident should have been monitored and not sent out. CNA #3 further stated it was procedure to call the DON, ADON, or the Administrator before they could send a resident out. They stated they have to monitor the resident for approximately three days before sending residents to the hospital. CNA #3 stated I have never left feeling like I did not do my job until that night. It was all just wrong. CNA #3 was asked what injuries were seen on Resident #40. They stated, the right ear, right cheek, left hand, scalp, and hair were burned. On 01/09/23 at 5:55 p.m., LPN #1 stated they found Resident #40 on the floor in their room and asked them what they were doing. They stated the resident said they were trying to get up. LPN #1 stated they saw what looked like dirt on the floor and smelled smoke. LPN #1 stated they got the resident up and saw their hair was burned. They stated they did not know the policy on that since the residents hair was coming out and wanted to send them out to the hospital. LPN #1 stated they called the DON, who did not answer, so they called the ADON and was told to apply Silvadine, clean the resident up, and to give them a shower. LPN #1 was asked if they asked the ADON if they could send the resident to the hospital. They stated, Yes. They told me just to wait. They stated that at the time the resident did not look that bad except their hair. They stated the resident's head was light pink and the worst part was the resident's left hand. LPN #1 was asked if they called the residents physician. They stated, No. They were asked why not. LPN #1 stated because of the order they got from the people over them and that,to me she wasn't that bad. LPN #1 was asked if the resident should have been sent to the hospital using their nursing judgement. They stated, Because of what happened, Yes, not because of the injuries. LPN #1 further stated if they had been at their old job where they knew the expectations then they would have sent the resident to the hospital. LPN #1 stated since they were new to the facility they did not know the procedures and since the injuries were not that bad, and the resident's lungs did not sound that bad, they wanted to send the resident because of what had happened and to make sure there was not anything that they did not see. LPN #1 was asked if Resident #40 complained of pain. They stated not that they remembered. On 01/09/23 at 6:07 p.m., CNA #2 stated LPN #1 found Resident #40 in the floor on 12/26/22 at approximately 11:15 p.m. CNA #2 stated LPN #1 called out for help. CNA #2 stated Resident #40's room was filled with smoke and smoke was seen in the hallway, Resident #40 was lying on the floor on their stomach. CNA #2 stated Resident #40 had brown residue on the oxygen nasal prongs. CNA #2 stated Resident #40 had burns on their ear, the skin was coming off, and the ear was really red. CNA #2 stated Resident #40's hair was burnt and had to be cut off. CNA #2 stated LPN #1 contacted the ADON by phone and asked if Resident #40 should be sent out. CNA #2 stated Resident #40 had not been sent to the hospital the night the burn had occurred. On 01/10/23 at 11:14 a.m., the Medical Director/Attending Physician was asked if they were notified of Resident #40's recent incident. They initially could not recall, but then stated the resident burned themselves smoking in their room and had burned their hair, face, and left hand. The Medical Director were asked when they were informed, They stated, I think so. They were asked when. They stated the same day. They were asked if they gave any orders. They stated, I think they used Silvadine. The Medical Director was asked if they gave the order for Silvadine. They stated, Yes, they used Silvadine. They were asked who they gave the orders to. They stated they did not remember and that they usually give orders to the nurse on call. The Medical Director/Attending Physician further stated they stopped in within the next couple of days and looked at the residents hand. They were asked if the appropriate treatment was provided to the resident at the time of the incident. They stated they thought so. They were asked if they gave orders to send the resident to the hospital. They stated, I don't think so. On 01/10/23 at 5:46 p.m., ADON stated they could not find the fax sent to the physician by LPN #1. On 01/10/23 at 4:47 p.m., wound care to resident #40's left hand was observed. The resident's left thumb had a deflated blister with no drainage present, the index finger had a deflated blister with no drainage, the middle finger had a deflated blister with clear drainage, the ring finger, both the top and underside, had a deflated blister with clear drainage, the pinky finger, both the top and underside, had a deflated blister with clear drainage, and the palm of resident #40's left hand had a small dark, dry spot. The resident stated their wounds were tender to touch. The right ear was observed scabbed and pink with no drainage. On 01/11/23 at 5:30 a.m., LPN #1 stated they had not had specific training on determine the severity of a burn. LPN #1 stated Resident #40's left hand was darker pink than the scalp, ears, and face, and had developed blisters by the morning. LPN #1 stated they had done neurological checks through the night because Resident #40 was found on the floor. LPN #1 was asked if they had assessed Resident #40's lung sounds, oxygen saturation, size, and degree of the burns. They stated they thought they did. There was no documentation of Resident #40's lung sounds, oxygen saturation, or description of burns. On 01/11/23 at 6:32 a.m., LPN #2 stated they were notified Resident #40 had caught themselves on fire smoking while wearing oxygen in their room. LPN #2 stated Resident #40 had big blisters on the left hand and the fingers were swollen and bubbled up. LPN #2 stated they notified the physician of the burn between 6:30 a.m. and 7:00 a.m. and received an order for Silvadine to be applied to the burns. LPN #2 stated they assessed Resident #40's burns, lung sounds, and pain. LPN #2 was asked if they had documented the assessment. They stated No. LPN #2 was asked if they would have sent Resident #40 out if the burn had occurred on their shift. They stated Yes, because Resident #40's head was burned. LPN #2 stated if Resident #40 had went out for treatment and or evaluation the hospital could have ensured they were doing the correct wound care for the burn.

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 12/26/22 related to the facility's failure to ensure a resident who smoked was free from accident hazards. The facility failed to prevent a major injury while smoking with oxygen in use for resident #40. Resident #40 sustained burns to top of scalp, left hand, face, right and left ear. On 01/11/23,the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to protect and prevent accident hazards related to smoking in the building while wearing oxygen. The past noncompliance IJ was removed effective 12/27/22 after the facility put measures in place to prevent recurrence. On 12/27/22 staff was in-serviced about the smoking policy, all residents who smoked were inserviced on the smoking policy and signed the policy, the smoking policy was observed along with the smoking times hanging in every room of a resident who smoked. The facility performed smoking evaluations on all residents who smoked on 12/27/22. On 01/09/23 at 4:04 p.m., residents were observed during smoking. The staff was observed to obtain the cigarettes and lighters from the nurses' station, each resident was handed one cigarette and the staff lit the cigarette for each resident. The staff stored the cigarettes and lighter at the nurses' station after the residents finished smoking. All residents were observed as they smoked. Based on record review, observation, and interview, the facility failed to ensure residents did not smoke while wearing oxygen for one (#40) of two residents reviewed for accident hazards who smoked and had orders for oxygen. The Administrator identified two residents who had orders for oxygen and nine additional residents who smoked. Findings: Resident # 40 had diagnosis which included dyspnea, vascular dementia, and heart failure. A SMOKING POLICY AND PROCEDURE, revised 8-04-20, read in parts,This facility will comply with all federal, state, and local regulations regarding smoking in a long term care facility .Smoking or possessing a lighted tobacco product .is prohibited in the facility .The facility's tobacco use policy shall be clearly posted .resident or their legal representative shall be notified of the policy prior to admission .Residents must be accompanied by staff, family, or properly trained volunteers while smoking .Smoking materials will be kept in a designated are accessible only by staff .Smoking is prohibited in all areas of the facility except the designated smoking area . A Physician's Order, dated 12/14/22, documented to administer oxygen at two liters as needed for shortness of breath or decreased oxygen saturation. An annual resident assessment, dated 12/24/22, documented Resident #40's cognition was moderately impaired, was independent with transfers and walking with walker, used tobacco and received oxygen. A Care Plan initiated 12/26/22, read in parts . [resident] has increased shortness of breath .O2 @ 2L/M via N/C PRN SOB or decreased SaO2 every 1 hours as needed [Resident] smokes several times a day with supervision .Revision on 12/30/22 .Conduct safety evaluations on admission and PRN .DISCUSS WITH THE FAMILY THAT WHEN [RESIDENT] GOES OUT WITH THEM NOT TO GIVE [RESIDENT] ANY SMOKING MATERIALS TURN IN TO THE STAFF AT THE NURSES STATION .Educate Residents/Responsible Party on the facility's tobacco/smoking policy(s) .orient Resident to smoking times and procedures .Staff to extinguish cigarettes .Revision on 01/01/23[resident] has actual impairment to skin integrity D/T BURN of the left hand and ears .Weekly skin assessments treatments documentation to include measurement of each area of skin injury type of tissue healing and exudate and any other notable changes or observations . An incident report dated 12/26/22 at 11:15 p.m., read in parts, .resident lying on floor, face down, by recliner .trying to locate where smoke smell was .observed brown material on the floor .hair was burnt, hair was falling out in melted clumps .superficial burn to right upper scalp, other burns observed .applying first aid .type of injury . burn .injury location .Top of scalp .left hand (palm) .Face .Right ear .Left ear . A Progress note dated 12/27/22 at 3:33 a.m., read in parts, .observed resident lying on the floor face down in front of recliner .smelled smoke .observed brown colored matter, on the floor around resident's head .realized that hair was burnt, and falling out in melted clumps .has what appears to be superficial burn on right upper scalp, blisters on 2,3,4,5, digits of left hand, burn mark from O2 tubing to right cheek, both ears burnt, O2 tubing was burnt an changed, contacted ADON who commented they would evaluate resident in morning .fax to PCP . No fax document found in the clinical record. A smoking evaluation, dated 12/27/22, read in parts, Supervision will be required for all Residents during designated smoking times. This evaluation will be utilized for the Resident's smoking care plan on admission and as indicated .Poor vision or blindness .Balance problems while sitting or standing .Lethargic/falls asleep easily during tasks or activities .Burns skin, clothing, furniture or other .Unable to light a cigarette safely .Unable to hold a cigarette safely .Unable to extinguish a cigarette safely .Unable to use ashtray to extinguish a cigarette. (The above mentioned were areas marked yes on the evaluation.) The smoking evaluation did not address oxygen use while smoking. There were no other smoking evaluations found prior to 12/27/22. On 01/09/23 at 2:21 p.m., Resident #40 was asked if they smoked. The Resident's roommate stated the resident caught [their] hair on fire. Resident #40 was asked to explain. They stated once put the cigarette in my mouth then light the cigarette, then boom. I had oxygen on. The Resident stated they caught their hair on fire and had to get it cut. The Resident was asked if they normally smoked while wearing their oxygen. They stated not normally. Resident #40 stated they knew they were not suppose to smoke in the room. Resident #40 stated they were sitting in their recliner smoking when they caught on fire. The resident stated they had been smoking in their room because they had not finished their cigarette when they were outside. Resident #40 stated the staff were not aware they were smoking in their room. Resident #40 was asked how they got the cigarette and lighter. They stated, someone gave it to them and did not remember who. Resident #40 stated CNA #2 stated I was still lit up. The Resident was asked if they had any injuries other than their hair being burned. They stated, Yes. They stated burned their left hand, right ear, and part of their scalp. During the interview with resident #40, their right ear was observed to be scabbed and their left hand was bandaged. On 01/10/23 at 1:44 p.m., CMA #1 stated they had an in-service concerning the smoking policy after a resident had caught themselves on fire while smoking with oxygen on. CMA #1 stated the residents were not allowed to smoke unsupervised and all lighters and tobacco products were stored at the nurses' station. CMA #1 stated prior to in-service residents would go out and come back with smoking paraphernalia. CMA #1 stated the facility let all of the families and residents know the cigarettes and lighters would be stored at the nurses' station. CMA #1 was asked how the facility ensured the residents did not have cigarettes or lighters. They stated while providing care and throughout their shift they would check to see if they noticed any smoking materials in the rooms. On 01/10/23 at 1:54 p.m., the Administrator stated Resident #40 had been on a visit with family. The Administrator stated social services contacted Resident #40's family to discuss how Resident #40 had the cigarettes and lighter. The Administrator stated the family reported they had given the resident the cigarettes and lighter and failed to report it to the facility when the resident returned. The Administrator was asked what measures were put in place after Resident #40 had caught on fire. They stated social services, and the DON met with every resident who smoked on 12/27/22 and reviewed the smoking policy and asked the residents for the smoking materials. The residents agreed to follow the policy, signed the policy as acknowledgment, and gave the staff their smoking materials. They posted smoking policies and had an In-service with all staff on the smoking policy. The Administrator stated the social service had educated the family to ensure they disclosed the resident had been given smoking material and to give the facility the smoking material when the resident returned from a visit. They were notified to turn the cigarettes in with the nurse if they purchased cigarettes for the residents. The Administrator was asked if there were any extra precautions taken to ensure residents who were on oxygen did not have smoking materials in the room or were smoking. They stated when they went out for smoke breaks staff ensured the resident did not have their oxygen on. The Administrator stated they have residents who try to sneak and retain their cigarettes, and would not always disclose. They stated when there was cause or suspicion staff would ask them to allow them to look in their room and show them what was in their pockets. On 01/10/23 at 2:14 p.m., the DON stated that social services interviewed Resident #40's family. They stated all residents who smoked were educated by the DON, ADON, and social services about the smoking policy, smoking times, and they asked the resident's if they had any tobacco product with them. They stated two of the residents gave them what they had, no one else had any smoking materials at that time.