**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure all residents who smoke did so safely and did not take immediate action when a resident was identified as smoking while wearing oxygen for 2 of 2 residents reviewed for smoking (R2 and R7). The facility's failure to implement safety and accident prevention measures for residents that smoke created a finding of immediate jeopardy that began on 12/11/21. The nursing Home Administrator (NHA A) was notified of the immediate jeopardy on 3/16/22 at approximately 2:15 PM. The immediate jeopardy was removed by the facility on 3/16/22. The deficient practice continues at a scope and severity of a D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include The facility's smoking policy, effective 5/9/19, includes the following: *Smoking use includes the use of smokeless tobacco, cigarettes, e-cigarettes, and vaping *Residents who smoke shall have a nicotine assessment completed upon admission, quarterly annual and PRN. *Residents or visitors who do not comply with procedure may be asked to restrict or relinquish smoking privileges *A resident is determined to be a hazardous smoker if he/she demonstrates one or more of the following risk factors and will have a care plan developed that may also include room and pocket searches: smoke in unauthorized areas, give cigarettes or lighting materials to others *Residents who smoke will keep nicotine materials in a locked box in a secure designated area when not in use *There will be no sharing of nicotine products and/or lighters *Residents are not to maintain items in their rooms *Oxygen tanks are not allowed in nicotine use areas and must be removed and maintained in the center prior to exiting the building for smoking. According to information from OSHA, a normal environment is one that is comprised of 16.5 - 23% oxygen. This level changes to one of oxygen-enrichment both around the oxygen tank, because of the venting that occurs, and around the nasal cannula. An oxygen-enriched environment makes the air highly combustible and makes burning more efficient. A spark from a match, a lighter, or a cigarette, could cause lit materials to combust and burn more vigorously and hotter (between 1500 - 3000 degrees F.) As a result, various sources advise keeping flames five to six feet away from anyone receiving oxygen. About 45 people die each year in the United States, and more than 1,000 are burned from fires fueled by home oxygen equipment, mostly caused by smoking, according to the National Fire Protection Association. BOC Home Health Care writes, Smoking around oxygen is extremely dangerous and may cause clothing and hair to catch fire and burn much more vigorously than in air. Never smoke or allow someone else to smoke nearby whilst using your oxygen equipment .Your clothing could become enriched with oxygen as you use your medical oxygen. Clothing and materials which become enriched with oxygen will burn vigorously if ignited. Your clothing will continue to be enriched, even after you have turned off your oxygen supply. This company recommends that oxygen users ventilate their clothing for 20 minutes in open air before smoking. (www.bochomeoxygen.co.uk) The New York State Office of Fire Prevention and Control gives these warnings: Stay at least five feet from gas stoves, candles, lighted fireplaces and other heat sources. Keep oxygen cylinders and vessels in a well-ventilated area (not in closets, behind curtains, or other confined space). The small amount of oxygen gas that is continually vented from these units can accumulate in a confined space and become a fire hazard. (https://www.health.ny.gov/prevention/injury_prevention/children/toolkits/fire/docs/home_oxygen_fire_safety.pdf) An online demonstration by Vitas Healthcare shows how much more quickly a fire ignites and burns, and burns hotter, in an oxygen-enriched environment. (https://www.vitas.com/family-and-caregiver-support/caregiving/providing-care-at-home/demonstrations-the-dangers-of-oxygen-and-smoking) Example 1 R2 was admitted to the facility on [DATE] and has diagnoses that include COPD (Chronic Obstructive Pulmonary Disease), chronic respiratory failure and chronic heart failure. Her most recent MDS (Minimum Data Set), dated 12/9/21, shows a BIMS (Brief Interview for Mental Status) score of 8, indicating R2 is moderately cognitively impaired. R2 has orders to use oxygen every shift for COPD. The facility conducted a nicotine assessment for R2 on 12/3/21 that states R2 does not currently smoke. A facility progress note dated 12/11/21 at 12:03 PM states, Found patient lying in bed smoking. This writer turned oxygen off and took cigarette away from patient and placed in sink. R2 told Surveyor on 3/16/22 at 3:33 PM that she bought the cigarettes before she was admitted to the facility and brought them with her. R2 stated she had been smoking her whole life. The facility did not complete a nicotine assessment for R2 until 1/16/22. This assessment noted that R2 currently smokes, has been smoking for 40 years and smokes 1-2 times per day. The assessment also stated R2 was assessed to be able to smoke independently. Additionally, the facility added smoking to R2's care plan on 1/16/22. The care plan states, Focus: At risk for smoking related injury related to smoking independently .Goal: Maintain independence safely while smoking .Interventions: Remove supplemental oxygen device prior to entering designated smoking area. A facility progress note on 3/13/22 at 12:43 PM states, Resident was observed outside with stepdaughter and was smoking a cigarette while she had her oxygen tank on back of wheelchair. When they came in, I reminded her and her stepdaughter that if resident wants to go outside to smoke, she must leave her oxygen tank at the nurse's station, and we will put it back on her when she comes back in. Resident stated, I'm not doing that. The facility presented R2 with a risks vs benefits on 3/14/22, which stated R2 was to leave her oxygen in the building and if not could result in Catching on fire, blowing self-up, blowing others up, leading to death. On 03/16/22 at 12:03 PM, Surveyor interviewed LPN C (Licensed Practical Nurse), who wrote the note detailing R2 smoking outside with oxygen tank. LPN C stated she was passing medications in the hallway when CNA D (Certified Nursing Assistant) came up to her and said R2 was outside smoking with her oxygen on. LPN C stated she was unsure of how long it was between when she was told of the event and when R2 came back in the building, but thought it was 5-10 minutes. LPN C stated she did not go outside when she was notified but waited until R2 came back into the building. When R2 entered the building, LPN C was then at the nurse's station and notified R2 and her family that R2 needed to leave her oxygen tank at the nurse's station before leaving the building to smoke. LPN C stated she had seen R2 outside earlier sitting around with her family but didn't think anything of it because she (R2) had agreed in the past to turn her oxygen off. When asked if she should have intervened immediately upon being notified of R2 smoking outside, LPN C stated, It was the weekend, and I was so busy in here. Additionally, LPN C stated she had not received any education after the event on the smoking policy or the need to intervene when a resident is smoking while wearing or near oxygen. On 3/16/22 at 11:34 AM, Surveyor interviewed CNA D who stated staff usually help R2 outside to smoke and that she is supposed to leave her oxygen tank inside but sometimes she doesn't. When asked how she goes outside and smokes if she has her oxygen, CNA D stated, Well she (R2) said she turned it off. On 3/17/22 at 2:31 PM, CNA D told Surveyor that she had told LPN C on 3/13/22 about R2 being outside while wearing her oxygen and LPN C told her (CNA D) that it was OK as R2 was instructed to turn her oxygen off. CNA D also stated that she had not received any education on the smoking policy following the observation of R2. No evidence was found or provided that the facility provided any education to staff regarding the facility's smoking policy or the need to act when a resident is observed smoking with oxygen on or nearby. On 3/17/22 at 9:00 AM, Surveyor interviewed FM E (Family Member) who stated that some of the nurses and aides at the desk had told her that R2 needs to take her oxygen tank off before she could go outside and smoke. FM E went on to say, So one day I went up to the desk and asked if as long as I'm with her (R2), can I just keep her tank on her wheelchair but turn the oxygen off and the staff told me that was OK. FM E was unable to remember who the staff was but stated this happened some time in February. Additionally, FM E stated it became a hassle to continually look for staff to get R2's smoking materials at the desk, so she would simply bring materials for R2. FM E stated that perhaps that was not the best idea. FM E stated the facility should have talked to her sooner about the oxygen, the policy, and their expectations to leave the oxygen tank inside the building. FM E stated, Certain staff will allow me to take her out smoking with the oxygen tank and others will not. On 3/16/22 at 1:18 PM, Surveyor interviewed DON B, who stated LPN C should have been more proactive about R2 smoking outside with her oxygen and should have intervened as soon as it was known R2 was smoking while wearing or near oxygen. Example 2 R7 was admitted to the facility on [DATE] and has diagnoses that include heart failure. Her most recent MDS, dated [DATE], shows a BIMS score of 15, indicating R7 is cognitively intact. R7 has orders for oxygen as needed. R7 stated to Surveyors on 3/14/22 at 7:25 PM that she only wears her oxygen when in bed, but does so every night. The facility documented the following progress notes for R7: 4/15/21 at 1:09 AM: This writer went and check, and we could smell the smoke going in her room. Resident denies that she smoked, and said she was just watching television. This writer asked resident where her cigarettes were and she said, I don't have any! This writer asked resident if I can look inside her bag and she said yes. This writer found 1 pack of cigarette and a lighter, oxygen is on; after a long talk and education with her she states I am sorry I lied to you! You don't know what I am feeling right now, I just want to go home! per statement. Will contact DON (Director of Nursing) in the morning. 4/22/21 at 3:30 PM: Executive Director was notified by CNA that she saw an e-cigarette on resident's bed while turning her and the e-cigarette was warm. It was immediately removed from resident's room and stored away appropriately. 5/18/21 at 8:35 PM: Resident has been in and out facility to smoke, she wakes up around midnight wanting to go outside to smoke. This writer told resident No! the cut off time was 10:00 PM and it's facility policy for safety purposes. Resident begging this writer to go out, told resident that she just has to wait until the morning. 5/23/21 at 10:45 PM: Resident went out to smoke and told CNAs that this writer said okay for her to go out at this time. This writer approached resident by the entry door as to why she's going out to smoke at this time when she has been told about the facility policy about smoking schedule, and she said, You told me I can go out, and nobody talked to me about the policy you're talking about!. DON was notified and aware. Resident refusing to come back inside and still pursuing to go out and smoke. 7/28/21 at 5:43 AM: Resident was informed and educated about smoking times. 3:30 AM resident came out and asked to go smoke. She was told no; it is not a smoking time. She said well I want to go out please. She then headed for the door. This nurse told her she cannot be physically stopped. She continued outside to smoke. 7/28/21 at 10:36 PM: Resident is insisting to go out to smoke, she said she was asleep since 8pm. This writer re-oriented and re-educated resident about smoking schedule and that she was awake at 2100 because she asked for Norco and went outside to smoke. Resident did not remember that she went outside and said she's been in bed. 7/31/21 at 4:41 AM: Resident was educated on smoking times. She went outside twice this NOC shift following a warning that she needs to not go out since it is not an authorized smoking time. 8/12/21 at 12:21 AM: Resident went out to smoke after smoking hours. She stays by the building for safety. 8/9/21 at 11:21 PM: Resident went out to smoke and states the facility has been letting her out to smoke now. 8/30/21 1:36 AM: Resident went out to smoke again. This writer told her it's not scheduled to go out, and she states I can go out whenever I want now 1/18/22 10:55 AM: Resident made aware of our smoking policy. Resident has been non-compliant with smoking in designated smoking area. Placing rock in door. Not having nicotine locked up. Sharing cigarettes and not putting cigarette butts in the proper place. All these concerns discussed with resident. Gave copy of smoking policy. Discussed smoking cessation. Resident denies wanting to quit smoking. All smoking materials locked in nurse's station room. R7's care plan for smoking, dated 4/22/21 states, Focus: Resident is a smoker. History of smoking in community/inappropriate smoking related to non-compliance with policy. On 3/14/22 at 7:25 PM, Surveyor interviewed R7 who stated she had been rolling her own cigarettes since October of 2021. She lent a cigarette to R2 on 1/14/22 and as a result, the facility confiscated all her cigarette supplies. R7 stated that she could get her supplies from the nurse and roll cigarettes in the activity room. R7 stated she did this a few times, but then due to the hassle of getting into the activity room, she decided to keep her supplies. R7 was not sure the exact date she did not give her supplies back but it was within a few days of being confiscated. R7 stated that nobody had taken the supplies back since that time in January. R7 also stated that she regularly rolls cigarettes in her room and has not tried to hide it. R7 was sure staff had seen her rolling cigarettes in her room since January. On 3/15/22 at 3:54 PM, Surveyor observed R7's smoking supplies in her room. R7 pulled her lighter out of her pocket when asked if she had one. R7 then stated she doesn't have anything at the desk where the supplies are supposed to be kept. On 3/15/22 at 3:50 PM, Surveyor asked LPN C where resident smoking supplies were, to which she replied she did not know. At 4:10 PM, Surveyor observed CNA F and CNA G at the nurse's station. When asked where the smoking supplies were at, CNA F stated R7 does not keep her stuff at the desk, she keeps them in her room. CNA F stated she did not know R7 smoked. On 3/16/22 at 11:30 AM, Surveyor interviewed CNA H, who primarily works the night shift. CNA H stated R7 does go out to smoke at night, but that she (CNA H) doesn't ever pay any attention to where she (R7) gets her smoking supplies. CNA H stated she knows what R7 is supposed to do, but wants to treat R7 with respect. CNA H stated the smoking supplies are supposed to be locked up at the desk, but staff doesn't keep track because R7 is so independent. On 3/16/22 at 11:34 AM Surveyor interviewed CNA D and CNA I, both of whom stated R7 did not keep her smoking supplies at the nurse's station, and they had seen R7 rolling cigarettes in her room within the last few weeks (unable to recall specific dates). On 3/16/22 at 12:39 PM, Surveyor interviewed DON B who stated R7's smoking materials should be locked up in the medication room behind the nurse's station. Surveyor and DON B went to med room and unlocked the metal case where resident smoking supplies are to be locked up. Only R2's smoking materials were in the case. Nothing for R7 was in the case. When asked if there was anywhere else R7's smoking supplies would be stored, DON B stated no. On 3/16/22 at 4:21 PM, Surveyor interviewed RN J (Registered Nurse), who stated DON B took R7's smoking materials earlier in the year. RN J stated R7 goes out whenever she wants to smoke, and she (RN J) doesn't get any supplies for R7 when she goes out and has stuff in her room. Additionally, RN J stated R7 doesn't follow the facility's smoking policy. On 3/16/22 at 1:18 PM, Surveyor interviewed DON B who confirmed that R7 had lent a cigarette to R2, had had her cigarette supplies confiscated as a result and could only access them from the nurse's station. DON B also stated the facility should have had a more proactive approach to keeping the smoking supplies out of her room. The facility was aware R2 and R7 had a history of non-compliance with the facility's smoking policy and did not ensure the residents and staff understood and implemented the facility's smoking policy to ensure R2's and R7's safety. R2 was observed smoking with oxygen on 12/11/21 and the facility did not complete a smoking assessment or care plan for R2's smoking use until 1/16/22. When R2 was observed smoking while wearing her oxygen again on 3/16/22, the facility did not intervene as they believed the oxygen was simply off. R7 was observed, and admitted to, smoking with oxygen on inside the building and was also observed with a hot e-cigarette on a later date. Although the facility tried to confiscate R7's smoking materials in January 2022, R7 was able to get them back within a few days and, although the facility care planned R7's non-compliance with the smoking policy, continued to allow R7 to smoke independently and did not take steps to ensure she did not have smoking materials in her possession. The facility's failure to implement safety and accident prevention measures for residents that smoke created a reasonable likelihood that serious harm could occur. This led to a finding of immediate jeopardy. The facility removed the immediate jeopardy on 3/16/22 when it implemented the following: ~All staff educated prior to their next working shift on the following ~Facility smoking policy ~Secure smoking materials from residents that smoke ~Timely completion of nicotine assessment ~Removing oxygen tanks prior to allowing residents to smoke ~Family Member educated that oxygen tanks must be removed by staff prior to resident smoking. ~Smoking materials were secured by NHA and DON ~Interdisciplinary team completed full house sweep for any unsecured smoking materials. ~DON completed a new nicotine assessment on residents. ~DON/designee will audit residents for securement of smoking materials every shift for 4 weeks. ~DON/designee will audit staff removal of oxygen tanks every shift for 4 weeks. ~Results of audits will be brought to monthly Quality Assurance and Performance Improvement meeting for review and recommendations until compliance is achieved.