Lemon Grove Care & Rehabilitation Center
Citation Number: 090005704
Citation Date: 12/17/2008
Violation Date: 3/31/2008
Class: AA
Penalty: $ 80000.00

CFR 483.25(h)(2) Each resident receives adequate supervision and assistive devices to prevent accidents.

The facility failed to provide adequate supervision to ensure the safety of one skilled nursing resident who smoked in the facility's designated smoking area (gazebo). On 3/31/08 at 11:00 A.M., Resident A was out in the gazebo with 2 other residents to smoke. There were no staff members or responsible adults present in the gazebo to assist, monitor, or supervise the residents. Resident A pulled her nylon jacket over her head to block the wind as she lit her cigarette. Her nylon jacket caught on fire and the flames quickly spread to her hair and upper body. She sustained second degree burns (blistering of the affected skin with pain) and third degree burns (white and red areas involving deep tissues) to her face, head, neck, chest, upper arms, and fingers. She was transferred to the acute hospitals' trauma burn unit for treatment of 2nd & 3rd degree burns to 20 % (percent) of her body. On 4/10/08, ten days after the incident, Resident A died at the hospital from cardiogenic shock due to multiple myocardial infarctions and ongoing ischemia secondary to 20 percent total body surface area burn. The death certificate listed Resident A's immediate cause of death as "Complications of thermal burns."

On 4/1/08 at 9:22 A.M., the Director of Nurses (DON) sent a letter to the Department to report that on 3/31/08, Resident A caught on fire while smoking in the smoking patio. The report read in part; "Yesterday at about 11:00 A.M., (Resident A's last name) was out on the smoking patio. She related the following, "I was trying to light my cigarette and I pulled my jacket up to block the wind..." At some point, (Resident A) jacket caught fire. The receptionist noted smoke and flames coming from the smoking area and saw the resident's torso engulfed in flames. The receptionist called for staff assistance, pulled the fire alarm and called 9-1-1."

An onsite visit was conducted at the facility on 4/2/08 at 7:30 A.M.

A review of Resident A's medical record was conducted on 4/2/08 at 8:00 A.M.

Resident A was a 74-year old female who was admitted to the facility on 7/25/07, with diagnoses that included dementia and memory loss, per the Record of Admission. The admission minimum data set (MDS) assessment dated 8/10/07, indicated that Resident A required extensive assistance (staff performed part of the activity for the resident) in performing activities of daily living such as turning from side-to-side when lying in her bed, transferring to/from bed or wheelchair, putting on or taking off clothing, transferring on/off toilet, and combing her hair or brushing her teeth.

The Activity Assessment Form dated 8/8/07 indicated that Resident A's preferred primary activity was smoking in her room and in the patio/gazebo. The same assessment indicated that Resident A needed assistance to perform the activity (smoking) while out on the patio.

The plan of care dated 8/10/07 identified that Resident A smoked daily and had potential for injury related to smoking. The care plan interventions included the following:

1. Explain facility smoking policies to resident. 2. Monitor resident to assess compliance with facility smoking policy. 3. Repost incidents of non-compliance to supervisor. 4. Evaluate the need for removal of smoking materials.

The initial Smoking Safety Screening assessment dated 8/10/07, contradicting the above plan of care, indicated that Resident A could smoke without restrictions.

On 11/21/07, Resident A was found smoking in the patio outside her room, which was a non-designated smoking area. The facility intervened by moving the resident to another room with no outside access, and then completed another Smoking Safety Screening assessment on 12/11/07. This time, the facility identified that Resident A required "constant reminders to smoke only in designated areas." There were no other interventions such as staff monitoring or supervision to ensure that Resident A remained safe, and in compliance with the facility's smoking policy.

On 4/2/08 at 8:20 A.M., the facility's Incident/Accident Report (IAR) dated 3/31/08 was reviewed. The report read as follows:

"Resident A was outside in smoking area under gazebo. She was attempting to light her cigarette. It was very windy, so she lifted her jacket around her head. Her jacket caught fire and the resident was engulfed in flames from the lower abdomen up, including torso, arms, and head. The receptionist saw something burning in the patio under (the) gazebo, called to activity person and pulled the fire alarm. PT (physical therapist) ran to the area and removed resident's shirt. Housekeeper extinguished flames with a towel. Paramedics on scene and took over care of the resident. Administrator also put out flames with fire extinguisher. Resident transported by paramedics/Fire Department to (hospital's name) ER (emergency room) burn center. O2 (oxygen) saturation 96% (percent), pulse rapid @ 111."

On 4/2/08 at 10:00 A.M., Resident C (witness) was observed and interviewed. He was alert, attentive, and spoke clearly. He stated that on 3/31/08 at around 11:00 A.M., he was in the gazebo to smoke with 2 other residents (Resident A and Resident B). Resident C stated that it was "very windy" that day. He stated that there were no staff members in the gazebo. He stated that Resident A lifted her jacket over her head to block the wind while she lit her cigarette. He stated, "All of a sudden, her jacket was on fire and spread to her head. I yelled for help and tried to put the fire out with my hands. I burned the tips of my fingers. It took at least 5 minutes before staff came to the gazebo." Resident C stated, "Staff does not come out to the gazebo to monitor or assist us when we smoke."

On 4/2/08 from 10:30 A.M. to 11:45 A.M, the following staff members were interviewed:

Housekeeper 1 (H 1) was interviewed through an interpreter. H 1 stated, "On 3/31/08 at 11:15 A.M., I was mopping the floor in the front lobby area near the nurses' station 1. I happened to glance out the glass sliding door which led to the patio area. I saw smoke and flames under the gazebo where residents were smoking. I yelled in Spanish, "demen una tuwalya!" (Get towels!), but no one understood what I was saying. I grabbed a small towel from my cart and ran out to the patio. The (Resident A) hair was on fire! I patted her head with the small towel."

The physical therapist 1 (PT 1) stated, "I was at the nurses' desk in station 1 when I heard two people yell, "Call 9-1-1! I ran to the front of the sliding glass door and saw a woman (Resident A) in the gazebo who was engulfed in flames. I ran outside and ripped her jacket from her upper torso. Other staff members came out to help. The flames were put out before the paramedics arrived."

On 4/8/08 at 3:15 P.M., a second visit was made to the facility. During this visit, Resident B was observed and interviewed. He was alert and spoke clearly. When asked of what he remembered about the burn incident on 3/31/08, Resident B stated that he was out in the gazebo smoking with 2 other residents (Resident A and Resident C). He stated that it was "very windy" that day. He stated that there were no staff members in the gazebo to check on them or to help them if needed. He stated that Resident A pulled her black nylon jacket over her head to block the wind while she lit her cigarette. He stated, "The jacket burst into flames and she started to burn. I yelled for help! It was a few minutes later before someone came out to the gazebo with an extinguisher."

On 5/1/08 at 9:42 A.M., a third visit was made to the facility. During this visit, the receptionist was interviewed. She stated; "On 3/31/08 at 11:15 A.M., I was walking past Station 1 to the front desk in the lobby area when I happened to glance towards the sliding glass door. I saw thick smoke rising upward towards the top of the palm trees. I back-tracked and followed the source of the smoke until I saw flames coming from the gazebo! There were 3 residents there and I thought to myself, what are they burning? I did not go out to the patio to check, but I walked towards the social services office. Before I got there, I looked back and saw that the flames were getting bigger. I saw that one of the three residents (Resident A) was engulfed in flames and was shaking from side-to-side. I then pulled the fire alarm and immediately called 9-1-1."

On 5/1/08 at 11:00 A.M., staff members were interviewed to determine what the facility's policies and procedures were regarding smoking, and how staff members supervised the residents who smoked in the gazebo. Each staff member responded as follows:

The social service designee (SSD) stated, "The facility does not have scheduled smoking times. The residents can smoke anytime they want, without staff members or other persons supervising them."

The licensed nurse 1 (LN 1) stated, "Visual supervision means that staff should be out in the gazebo with those residents who require supervision while smoking. Staff members are to make sure the residents are supervised and to make sure that they have a smoking apron on. After the (burn) incident, staff members are now required to be out in the gazebo to monitor or supervise the smoking residents."

The certified nurses' assistant 1 (CNA 1) stated, "Visual supervision means that staff were to stay out in the gazebo with the residents when they smoked. We have to make sure that the residents are safe and are wearing smoking aprons. We have to help them light their cigarettes if needed."

The LN 2 stated, "Responsible persons such as the certified nurses' assistant, receptionist, or activities staff were supposed to watch the residents. If the residents were deemed unsafe to smoke on their own, a CNA was sent with them to the smoking area. Resident A, Resident B, and Resident C were supposed to be monitored or supervised based on their smoking assessment, but no one did."

On 5/1/08 at 12:30 P.M., the distance from the reception area and the closest nursing station (Station 1) to the gazebo was measured to determine if staff members could provide "visual supervision" from inside the facility. The distance was 70 feet from the reception area to the gazebo and 60 feet from Station 1 to the gazebo. There was a sliding glass door 10 feet away from the reception area and on the left side of Station 1 that led out to the patio/gazebo. It was noted that staff members or anyone in the nursing station or by the reception area could not view or see the gazebo or the smoking residents unless they walked by or stood in front of the sliding door.

On 5/6/08 at 12:00 P.M., Resident A's husband was interviewed by telephone. He stated; "I visited my wife at least 6 times a week, from 3:00 P.M. to 6:00 P.M. We both smoked in the gazebo for 1 to 1 1/2 hours each time. I always lit her cigarettes for her. I never saw staff come out in the patio to help my wife or to monitor any of the other residents who smoked in the gazebo. I was concerned with my wife's safety when I was not with her and there was no staff to supervise or help her when she smoked in the gazebo. There should've been staff in the gazebo when my wife or the other residents smoked. I voiced my concerns to the facility during a care plan conference that I recently attended in 2/08. No one from the facility discussed what they would do regarding my concerns for my wife's safety when she smoked without staff supervision."

On 5/15/08 at 9:00 A.M., the following documents regarding Resident 1's burn incident were reviewed:

The emergency medical transport report dated 3/31/08 read as follows: "Incident date 3/31/08 11:00. Call received 11:20, Responding 11:21, Arrived scene 11:25, Departed scene 11:38, Arrived Destination 11:54. C/C (chief complaint) severe burns. HX (History)-Patient was sitting in her electric scooter outside courtyard under gazebo structure when she was lighting a cigarette and pulling up her jacket (apparently of flammable material) as a windbreak which ignited jacket and remainder of clothing. Clothing burned off onto ground leaving only adult diaper partially melted on pt (patient). Staff used fire extinguisher to extinguish flaming clothing. Staff applied towels and placed on O2 (oxygen) n/c (nasal cannula). AX (assessment)-found sitting on scooter under gazebo. Upholstery of seat and side rails partially melted. Physical exam reveals major burns including appx (appendages), singed scalp hair, singed nasal hair and black soot in nares (nostrils), 2nd & 3rd degree burns anterior torso, 1st/2nd degree burns both arms, 2nd/3rd degree burns left thigh, fingernails (possibly acrylic) melted. Patient states pain 8 out of 10, MS (morphine sulfate) 10 mg. (milligrams) administered w/o (without) change in pain." The acute hospitals' Discharge Summary Report dated 4/15/08 was reviewed on 5/15/08 at 10:00 A.M. The report read in part; "This is a 74-year old lady who sustained a 20 % burn to her anterior torso when she was trying to light a cigarette and the jacket that she was wearing caught on fire. An elective intubation (a tube inserted into a hollow organ or body passage) was carried out. On 4/4/08, the patient had debridement of her burns. She was transferred to the burn intensive care unit (ICU). On 4/9/08, the patient's systolic blood pressure started to drop to the 70's. Her blood pressure continued to fall and she eventually became asystolic (asystole is a state of no cardiac electrical activity; hence no contractions of the heart and no cardiac output or blood flow). A chemical code was carried out but was unsuccessful. She was declared dead on 4/10/08 at 4:29 P.M." The facility did not provide for the safety of Resident A who was deemed to require monitoring while smoking. Staff members disclosed in interviews that the facility did not have designated smoking hours, and did not have staff members assigned to monitor, supervise, or assist the residents who required supervision or monitoring when they smoked. Resident A required extensive assistance in completing daily living tasks. She was confused, had decreased safety awareness, and was non-compliant with the facility's smoking policy; and yet, the facility did not provide preventative measures such as routine or random monitoring by staff to ensure the resident's safety. Resident A had set herself on fire and sustained serious and life-threatening burns to 20 percent of her body because there were no staff members in the gazebo to assist her light her cigarette when it was windy; and, to immediately come to her rescue when her flammable nylon jacket caught on fire. Consequently, Resident A sustained 2nd & 3rd degree burns to 20 percent of her body. She died on 4/10/08, ten days after the incident, from cardiogenic shock due to multiple myocardial infarctions and ongoing ischemia secondary to 20 percent total body surface area burn. The certificate of death dated 7/15/08 listed Resident A's immediate cause of death as "Complications of thermal burns."

This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the resident.