**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to prohibit unsafe smoking practices for two (2) of 11 residents in the survey sample, Residents #1 and #6. Resident #1 was inaccurately assessed to be safe to have a cigarette lighter at the bedside. On 2/26/23, he lit a cigarette in his room, while receiving continuous oxygen therapy, resulting in harmful burns on his lip, ear, chest, and back. When the resident returned to the facility, the facility did not implement the newly revised care plan for 1:1 supervision to keep the resident safe. Resident #6, who was assessed to be an unsafe smoker, was observed by the surveyor lighting his own cigarette on 2/28/23 and 3/1/23. On 3/2/23 at 4:00 p.m., the ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, ASM #3, the vice president of operations, and ASM #4, the regional clinical director were informed that these findings resulted in a determination of harm at the level of immediate jeopardy. On 3/6/23 the survey team verified the removal plan had been fully implemented by the facility. On 3/6/23 at 2:40 p.m., ASM #1, ASM #2, ASM #3, and ASM #4 were informed the removal plan had been verified and the IJ had been abated. The scope and severity of the deficiency was lowered to a level 3, isolated. The findings include: 1. For Resident #1, the resident was inaccurately assessed to be safe to have a cigarette lighter at the bedside. On 2/26/23, he lit a cigarette in his room, while receiving continuous oxygen therapy, resulting in burns on his face, chest, and left flank. When the resident returned to the facility, the facility did not implement the newly revised plan for 1:1 supervision to keep the resident safe. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/8/23, Resident #1 was coded as being moderately cognitively impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring the extensive assistance of staff for bed mobility. He was originally admitted to the facility with diagnoses including COPD (chronic obstructive pulmonary disease) (1) and schizoaffective disorder (2). On 3/1/23 at 1:35 p.m. and 3:50 p.m., Resident #1 was observed by the surveyor lying in bed, with no staff in the room or within line of sight of the resident. A review of Resident #1's progress notes revealed: 2/26/23 Resident rec'd (received) order to be transferred to ER (emergency room) after receiving blisters to face, nose and back during his unauthorized smoking in bed. Resident is his own responsible party. 2/26/23 Resident admitted [to local hospital.]' A review of the facility synopsis of events dated 2/26/23 revealed, in part: [Resident #1] resides in [room number]. [Resident #1], who is oxygen dependent was smoking in his room and caught his (sic) self on fire. Fire put out and oxygen turned off and removed. [Resident #1] obtained a burn to the tip of his nose, right lower lip, burn to the right and left chest and left back. [Resident #1's] smoking material confiscated, and resident sent to emergency room for evaluation of burns. Investigation initiated. A review of Resident #1's hospital Discharge summary dated [DATE] revealed, in part: admit date : [DATE]. discharge date [DATE]. Chief Complaint: Trauma Major. Discharge Diagnosis: 5% TBSA (total body surface area) superficial partial thickness burn to face, chest, left flank .74 y.o. (year old) male with COPD on home O2 (oxygen) who was [NAME] to [local hospital] as an alpha trauma for management of flash burns to the face sustained while lighting a cigarette while on home O2 .[Resident #1] was admitted to the ICU (intensive care unit) for airway watch. There was no inhalation injury. He underwent burn scrub on the day of admission .He was transferred out of the ICU on 2/27. He was deemed medically ready for transfer back to his facility on 2/28. A review of Resident #1 most recent smoking evaluation prior to 2/26/23 revealed, in part: 1/31/23. Observations. 1. Resident is able to communicate why oxygen must always be shut off prior to lighting cigarette. No. 2. Resident is able to communicate the risks associated with smoking. No .4. Resident smokes safely. Yes. Summary of Evaluation: Resident is determined to be [a] safe smoker. Supervision needed while smoking: None. A review of Resident #1's care plan initiated 11/13/19, and in effect on 2/26/23 revealed, in part: 11/13/19 [Resident #1] is a smoker. Noncompliant with smoking policy .[Resident #1] is able to: light own cigarette, keep lighter at bedside. Date Initiated 2/12/19 .[Resident #1] requires supervision while smoking .[Resident #1's] smoking supplies are stored at the nurses station. A review of Resident #1's care plan initiated 2/28/23 revealed, in part: Resident is an unsafe smoker .will be educated on the risk of smoking with oxygen .[Resident #1] will be place (sic) on 1:1 supervision. A review of Resident #1's physician orders revealed the following order dated 1/28/23: Oxygen as Needed .2L/min (liters per minute) as needed. A review of the facility policy in place on 2/26/23 regarding resident smoking revealed, in part: Smoking - Supervised .The Center will provide a safe, designated smoking area for residents. For the safety of all residents, the designated smoking area will be monitored by a staff member during authorized smoking times. Smoking is only allowed in designated areas and during designated times. Oxygen is not permitted in the designated smoking area .Residents that wish to smoke will be evaluated on admission/re-admission, quarterly, and with a change in condition to determine if assistance or supervision is required for smoking. If a resident is identified during the smoking evaluation to require assistance or supervision with smoking, the Center will include the appropriate information in the care plan. The Center will establish and post designated smoking areas and times. During designated smoking times staff will be assigned to assist or supervise residents whose care plans indicate assistance or supervision is required while smoking. The Center will retain and store matches, lighters, etc. for all residents. On 3/1/23 at 9:24 a.m., LPN (licensed practical nurse) #1, Resident #1's unit manager, was interviewed. She stated the facility staff completes smoking safety assessments at least quarterly. She stated if she completes the assessment, she takes the resident outside to the designated smoking area to observe them smoking. She looks for changes since the previous assessment, for how the resident holds the lighter and lights the cigarette, how firm the residents grip is on the cigarette, and if the resident appropriately discards the cigarette but in a non-flammable receptacle. She stated she completed Resident #1's safe smoking evaluation on 1/31/23. She stated the resident wears oxygen all the time. She asked him what would happen if he smoked in his room while wearing oxygen, and he could not answer the question. She stated he also could not answer the question about the risks of smoking. She stated Resident #1 had always (prior to 2/26/23) removed his oxygen and gone downstairs to the designated smoking area to smoke. She stated that despite the fact that the resident could not identify the risks associated with smoking while [NAME] oxygen, she determined he was safe to smoke. She stated she based this on the premise that the resident would always smoke without wearing oxygen outside in the designated smoking area. When asked if Resident #1 should have been allowed to keep a lighter at his bedside on 2/26/23, she stated: Based on my assessment, he was safe to smoke. LPN #1 reviewed Resident #1's care plan in effect on 2/26/23, but made no comment specifically on Resident #1's safety of having a lighter at the bedside. She stated: At that time [2/26/23], the ones that can safely smoke, the residents were allowed to have smoking materials at the bedside. During the above interview, when LPN#1 was asked again if Resident #1 was safe to have a lighter at the bedside on 2/26/23, she stated: No. He was wearing oxygen in the bed all the time. He should not have been allowed to have a lighter at the bedside. She stated she was working on 2/26/23 when Resident #1's nurse asked her to go in and assess Resident #1. She stated the resident had pink areas on his chest and flank, and that areas on his face were extremely discolored. She stated the tip of the resident's nose was red and already blistered. She stated she called emergency services immediately. When asked what it means if a resident's care plan calls for 1:1 supervision. She stated it means that a CNA (certified nursing assistant) or other staff member must be sitting with the resident at all times. She stated the 1:1 supervision is a nursing intervention for a resident's safety, and does not require a physician's order. She stated when Resident #1 returned from the hospital on 2/28/23, the clinical team decided that 1:1 supervision was best for him due to safety concerns. On 3/1/23 at 10:43 a.m., LPN #8, who was caring for Resident #1 on 2/26/23 when he was burned, was interviewed. She stated she heard someone yelling from the vicinity of Resident #1's room. She stated when she saw Resident #1, there was no fire, but the resident obviously had been burned. She stated she could smell burned flesh. She stated she removed Resident #1's oxygen cannula, and put the cannula and oxygen concentrator out in the hallway. She stated the tip of the oxygen tubing was black from being burned. She stated Resident #1 had a blister on his right lip when his cigarette must have been positioned. She stated he had a blister on top of his chest. She stated Resident #1's roommate tried to communicate to her what had happened, but she could not understand him. She stated LPN #1 arrived to help her assess Resident #1. They turned him over, and saw a large blister on the resident's back. She stated she saw a lighter and two cigarette butts on the floor. She stated Resident #1 told her he had been smoking in bed. She stated LPN #1 called the physician emergency medical services. She stated Resident #1 was quickly transferred to the hospital by the paramedics. She stated she was not aware that Resident #1's care plan allowed him to have a lighter at the bedside. She stated she normally does not work Resident #1's unit. On 3/2/23 at 10:57 a.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of clinical services, and ASM #3, the vice president of operations, were interviewed. ASM #2 stated the facility staff complete a safe smoking assessment on admission, readmission, and quarterly. If residents are deemed to be safe smokers, they can smoke in the outside designated smoking area unsupervised. ASM #1 stated the facility employs a smoking attendant 24 hours a day, seven days a week in the designated smoking area as an extra precaution toward resident smoking safety. When asked how information regarding a resident's smoking safety is transferred from the smoking assessment to the care plan, and finally to the staff responsible for taking care of the resident), ASM #2 stated: MDS is supposed to update the care plan. Sometimes I update it, or the unit managers update it, too. When asked where residents who are assessed to be safe smokers are allowed to smoke, ASM #3 stated, everyone is supposed to only smoke in the designed smoking area in the outside courtyard. He stated that is the only smoking area. 2. The facility staff failed to assist Resident #6, who was assessed to be an unsafe smoker, with lighting a cigarette. On 2/28/23 and 3/1/23, Resident #6 was observed lighting the resident's own cigarette. Resident #6's diagnoses included but were not limited to Huntington's disease (1). A smoking evaluation dated 2/27/23 documented Resident #6 was an unsafe smoker who needed constant supervision while smoking and was not able to safely light a cigarette with a lighter. Resident #6's comprehensive care plan dated 11/16/21 documented, (Resident #6) is a smoker. Instruct (Resident #6) about the facility policy on smoking: locations, times, safety concerns . The care plan failed to document information regarding lighting a cigarette. On 2/28/23 at 4:07 p.m. and on 3/1/23 at 12:00 p.m., in the designated smoking area and in line of sight of the smoking attendant, Resident #6 lit the resident's own cigarette. During both observations, Resident #6 was observed with involuntary jerking movements of both arms, which required multiple attempts before successfully lighting the cigarette. On 3/2/23 at 9:24 a.m., an interview was conducted with LPN (licensed practical nurse) #1 (the nurse who completed Resident #6's smoking evaluation). LPN #1 stated that while completing a smoking evaluation, she observes how a resident holds a lighter, puts the lighter up to the cigarette, how the resident holds the cigarette and if the resident is able to put the cigarette into the receptacle. LPN #1 stated it was not safe for Resident #6 to light a cigarette because of all of the resident's movements. On 3/2/23 at 11:58 a.m., an interview was conducted with OSM (other staff member) #2 (the smoking attendant on 3/1/23). OSM #2 stated she was supposed to light all residents' cigarettes. OSM #2 was made aware Resident #6 was observed lighting the resident's own cigarette in her line of sight on 3/1/23. OSM #2 stated, It might have been a point where I was doing a couple of things: opening doors, making sure they (other residents) were coming in without tripping or falling and I did not see (Resident #6) lighting a cigarette. On 3/2/23 at 1:40 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of clinical services). ASM #2 stated staff should light a resident's cigarette if the resident is assessed as not being safe to light his own cigarette. On 3/2/23 at 4:00 p.m., ASM #1 (the executive director), ASM #2 and ASM #3 (the vice president of operations) were made aware of the above concern. Reference: 1. Huntington disease is a progressive brain disorder that causes uncontrolled movements, emotional problems, and loss of thinking ability (cognition) .Early signs and symptoms can include irritability, depression, small involuntary movements, poor coordination, and trouble learning new information or making decisions Many people with Huntington disease develop involuntary jerking or twitching movements known as chorea. This information was obtained from the website: https://medlineplus.gov/genetics/condition/huntington-disease/. On 3/2/23 at 4:00 p.m., after conversations with the long term care supervisors, the survey team met with ASM #1, ASM #2, and ASM #3 and informed them that the facility was in immediate jeopardy (IJ). The facility presented the following IJ removal plan which the team, after consultation with supervisory staff, accepted on 3/2/23 at 7:10 p.m. 1. Residents Affected by Deficient Practice Resident #1 - Resident #1's roommate extinguished the fire. Resident #1's oxygen was removed. Resident #1 was sent to hospital. Resident readmitted to facility on 2/28/23. Smoking assessment revealed resident is an unsafe smoker. Care plan has been updated to reflect unsafe smoking status. Resident will be placed on 1:1 supervision for safety. Resident will be reassessed as needed for safe smoking. If resident desires to smoke, he will be 1:1 supervision Resident #6 - Resident #6's smoking assessment and care plan have been reviewed and updated. Resident #6 is an unsafe smoker and requires supervision during smoking, to include assistance with lighting cigarette and smoking apron. Resident #6's smoking material includes cigarette and lighter; all smoking materials are being maintained in a locked cart by staff. 2. Other Residents Identified to be At Risk Current residents were interviewed to validate their wishes to smoke. Residents identified as smokers were assessed using safe smoking assessments to determine the need for supervision when smoking by DCS/designee. DCS/designee completed education with smokers in facility and/or RP on the policy and procedure related to smoking. Each resident/RP will sign contract. Adhoc resident council meeting was held to ensure they are aware of the facility's smoking policy and procedure. DCS/designee to educate all facility staff on the smoking policy and procedure to ensure all tobacco materials (lighters, tobacco products, vape or electronic cigarettes) are secured in medication cart or resident issued lock box. No staff member will return to duty without receiving education prior to the start of his/her next scheduled shift. DCS to provide designated smoke aid education on the role of smoke aid. No staff member will return to duty without receiving education prior to the start of his/her next scheduled shift. Residents identified as smokers will have his/her care plan reviewed and updated if appropriate to ensure safety and decreased potential for injury. Full sweep of residents identified as unsafe smokers. Assessed for any smoking material (lighters, tobacco products, and electronic cigarettes) with potential to cause or contribute to a burn type injury. Items found were removed from resident care areas by DON/designee and secured at nursing station or issued lock box. Facility maintenance director completed audit of all resident rooms identified with oxygen in use to ensure oxygen signage was posted outside the resident door. Fire drill was completed on all shifts to ensure that staff responded appropriately. Safety observation was completed by maintenance director to ensure designated smoking areas were equipped with approved ashtray, container, fire blankets, and appropriate receptacles. Adhoc QA meeting to review all information and documentation related to incident including policy review, audits, and internal POC. Adhoc QA meeting to review IJ template and updates to the original plan 3. Systemic Changes All staff in service initiated immediately regarding facility smoking policy with particular emphasis of ensuring smoking materials must be stored at the nursing station or personal lock box when resident is not in designated smoking area outside the facility. No staff member will return to duty without receiving education prior to the start of his/her next scheduled shift. Education was initiated regarding residents classified as unsafe smokers will have NO smoking material on them (lighters, tobacco products, E-cigarettes) or in their rooms. They must be kept with the smoking attendant. If the resident refuses to give smoking materials to the resident attendant, the resident will be placed on monitoring, and director of nursing/administrator will be contacted for further assistance. Smoking attendants are to light the cigarettes of all unsafe smokers and monitor them while they smoke. No staff member will return to duty without receiving education prior to the start of his/her next scheduled shift. Residents identified as unsafe smokers were provided education regarding tobacco material must be stored with smoking attendant. The education also included the resident attendant providing supervision and necessary assistance per the care plan, and action that will be taken if the resident does not comply with the process. The regional director of clinical services provided education to the clinical administration team (unit managers, assistant director of nursing and staff development) in regard to completing a smoking assessment. The assessment includes observing the resident while smoking. The resident care plan will be reviewed after completing the smoking assessment, and revised as indicated. The smoking assistant will be informed of any changes to resident plan of care in relation to smoking immediately. Residents identified as needing supervision with smoking will be given one cigarette once outside in the designated smoking area, and smoking aid will provide/or supervise the lighting of the tobacco product/or provide appropriate equipment. Smoking Aid will be available 24 hours, 7 days a week 4. How will the deficient practice be monitored to ensure compliance? The DCS/designee will conduct a weekly quality review of 10 residents on each unit weekly times four weeks, and then every two weeks times two months. The findings of these reviews will be reported in the monthly Quality Assurance Improvement Committee meeting for four months. The committee will review the findings to determine if further action is needed. 5. Date of Substantial Compliance 3/4/23 On 3/6/23 the survey team verified the removal plan had been fully implemented by the facility. On 3/6/23 at 2:40 p.m., ASM #1, ASM #2, ASM #3, and ASM #4, the regional clinical director, were informed the removal plan had been verified and the IJ had been abated. The scope and severity of the deficiency was lowered to a level 3, isolated. No further information was provided prior to exit.