| D’ ADRIAN CONVALESCENT CENTER Facility I.D. Number 0016147 Date of survey: 12/27/01 Incident Investigation of 12/24/01 "A" VIOLATION(S): The facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident in accordance with each resident’s comprehensive assessment and plan of care. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident. All necessary precautions shall be taken to assure that the residents’ environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents. Planning an up-to-date resident care plan for each resident based on the resident’s comprehensive assessment, individual needs and goals to be accomplished, physician’s orders and personal care and nursing needs. Personnel representing other services such as nursing, activities, dietary, and such other modalities as are ordered by the physician shall be involved in the preparation of the resident care plan. The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the resident’s condition. The plan shall be reviewed at least every three months. AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT NEGLECT A RESIDENT. Based on observation, interviews and record review, the facility failed to monitor and supervise 1 resident to prevent an accident. The resident, while in his room, with oxygen on , per nasal cannula, lit a cigarette, resulting in first, second and third degree burns to the resident's face and hands (R1). Findings include: R1 is a 57 year old male, with diagnoses, in part, of End State Renal Disease, Congestive Heart Failure, History of Alcohol Abuse, and Alcoholic Dementia. (Review of Clinical Record Face Sheet dated 12/19/01). R1 was assessed by facility as having both short-term and long-term memory problems, with modified independence cognitively, (Review of R1's nursing assessment dated 11/19/01). On R1's Care Plan, under "Safety", it states, "At risk for injury to self and other related to smoking." The Approach (s) are: 1) Report/investigate any smoke odors that shouldn't be there. 2) Nurse/other staff monitor that res. goes to smoke room and lights cigarette. 3) Remind res. that he can only smoke in designated area. 4) Praise compliance, (Review of R1's Care Plan dated 12/4/01). On 12/4/01 R1 was in his room smoking and the nurse (E7) discussed safety and fire hazards, (Review of Nurses Notes dated 12/4/01 and 1:50 P.M.). On 12/24/01 at 6:30 P.M., R1 was in his room. R1 had oxygen on, per nasal cannula. R1 had been readmitted to the facility, from the hospital , approximately 2 hours earlier and was on bed rest. Certified Nurse Aid (CNA), E4, smelled smoke on 300 Hall, summoned another CNA, E5, and went to R1's room. R1 was coming out of his bathroom and E4 and E5 observed his face was burnt, they called the nurse, E6, she called 911, laid R1 on the bed and applied cold cloths to R1's face while waiting for the fire department and ambulance. R1 was transported to the hospital and admitted to the Intensive Care Unit with 1st, 2nd and 3rd degree burns to his face and hands. R1's bed linens and clothing were not burnt. R1 had attempted to light a cigarette in his room on 12/4/01 and the nurse had gone over the smoking policy with him. (Interview with E3, 12/26/01 at 11:45 A.M, in the Administrator's office and review of Facility Incident Report). R1 had asked E4 for a cup of coffee. When the CNA returned with the coffee, she smelled smoke. E4 got E5 and went into R1's room. They turned the oxygen off, R1 came out of the bathroom saying, "Look at my moustache". He had wet paper towels and was rubbing his upper lip and the top of his head. E5 told him to lay down. The right side of his face was red and where the smile lines are around the eyes, was white. The nurse came in, picked up a cigarette lighter from the bedside table and asked R1 where he got it. R1's nose was burnt and CNA noted black pieces of plastic on R1's bed; the nasal cannula inserts. The inserts were black and melted. R1 kept saying, "It's bad, I really did it this time". R1's nose was bleeding, his hair was singed about half way back and his moustache was gone. One finger was black and there were black marks on his hands. The ambulance came and took him to the hospital. A cigarette butt was found on the floor, next to the bed. Since it was meal time, R1's roommate was not in the room at the time and there were only 2 other residents in their rooms on the hall. There was an odor of smoke and the room was hazy, but not filled with smoke (Interview with E5, 12/26/01 at 12:15 P.M. in room 201). R1 was not allowed to have a lighter recently and the facility staff started taking it away from him. He had to come to the nurses station for a light (Interview with E2, 12/26/01 in Director of Nurses office). When E6 arrived in R1's room she saw R1 standing at the side of his bed with wet paper towels in off his moustache. E6 checked R1 in on his re-admission but did not ask if he had a lighter, only because she is used to him not having one and it was her mistake. R1 had been up to the nurses's station 5 or 6 times after his re-admission, asking for a cigarette. E6 told R1 she was busy and would light his cigarette as soon as she had time. R1 usually would bum a light off someone in smoking room but since he was on bedrest, he didn't go to smoking room. Prior to his last hospitalization, on 12/22/01 R1 had always been safe with the cigarettes and lighter. E6 did not know what R1's Care Plan said regarding smoking, stating she didn't do Care Plans and didn't know what they said. E6 applied cold cloths to R1's face while waiting for ambulance. E6 did not call R1's physician because she figured once he got to the hospital, they would call his physician, (Interview with E6, 12/26/01 at 3:10 P.M., in Room 201).Written statements by E4, E5 and E8 confirmed the above. Interview with R1, at the hospital revealed he always had cigarettes and a lighter and he had forgotten he wasn't supposed to smoke with oxygen on, or in his room. Observation of R1 revealed the right side of his face red and shiny, his moustache was 3 small patches of hair on his upper lip. His right eye was swollen and he stated he couldn't see out of it. His right index finger was bandaged. R1's glasses lens on the right side was smoke covered. (Interview with R1, in his hospital room, 12/26/01 at 2:00 P.M). |