Montana Nursing Home Found Negligent
After Resident Is Badly
Burned While Smoking and Using Oxygen
After the Montana Health Department received a complaint about a facility, it conducted a Centers for Medicare & Medicaid Services (CMS) survey and determined that the nursing home was negligent for failing to supervise a woman who was severely burned when she lit a cigarette and caused her oxygen tank to ignite. She was unsupervised and outside the facility when the incident occurred, and she died several weeks later.
The resident had been admitted into the facility with a lung disease that restricts breathing and required her to have supplemental oxygen. She had previously been caught smoking unsupervised several times. A witness reported that about ten minutes passed before staff members found the woman and called the medical emergency squad.
The survey indicated that the facility failed to report the incident and that several of the facility’s staff were not clear about the facility’s policies and procedures regarding smoking. The report also noted that some residents were inappropriately allowed to administer their own medications. The CMS Survey classified the incident as an “immediate jeopardy” situation which means that the facility must take immediate action to protect the residents in order to maintain its Medicare and Medicaid funding certification.
Staff members who were interviewed by the inspectors reported that the nursing home’s management were aware that nurses were not enforcing the facility’s new smoking policy requiring nurses to keep cigarettes and lighters stored away from the residents. One staff member indicated that residents were allowed to keep cigarettes and lighters in their rooms.
The nursing home is reported to have successfully removed the immediate risk to the residents while state workers were still on-site. The facility later submitted a detailed corrective action plan that addressed all the issues the state identified.
Compliance Perspective
Failing to supervise residents while smoking—some using oxygen tanks—resulting in potential immediate jeopardy to their safety, may be considered negligent, substandard quality of care, and may jeopardize a facility’s ability to receive funding from Medicare and Medicaid.
Discussion Points:
- Review policies and procedures addressing safe smoking by residents and QAPI/QAA oversight responsibilities for ensuring safety for those who choose to smoke.
- Train staff on the facility’s smoking policies and procedures and any newly implemented corrective action plans.
- Periodically audit to ensure that residents who smoke are supervised, do not have uncontrolled access to cigarettes and lighters, and are not allowed to smoke while using oxygen.
