HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure adequate no smoking signage in patient rooms and areas oxygen was administered; failed to adequately assess and identify patients who smoke and the need to secure smoking materials; failed to educate patients regarding the dangers of smoking and oxygen use for one of one medical record reviewed (MR1); and failed to encourage patients who smoke alternatives to smoking while admitted to the facility (A0144). The failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patient.

On January 24, 2025, the survey team toured the nursing units and conducted staff interviews regarding their education received about how patients will be educated regarding the dangers of smoking in a patient room with oxygen present or administered. The nursing units were toured; No Smoking signs were observed on patient units and in patient rooms. The immediate education that was provided to staff regarding patient no smoking education was reviewed.

The survey team verified these immediate interventions were implemented and confirmed the facility's IJ was removed on January 27, 2025.

After secondary review the State Survey Agency returned onsite on February 5, 2025. The survey team toured the facility and observed No Smoking or use of smoking related paraphernalia at entrances throughout the facility. Staff were educated on policy changes implemented regarding assessing patients for smoking/tobacco use on admission; smoking materials will be considered contraband and will be secured from patients. Documentation for securing of contraband in the medical record was developed and validated. Staff were educated regarding providing smoking cessation, smoking alternatives to patients, and documentation in the medical record. Staff education was verified. In addition to drafting policy, and educating staff and patients, the facility identified the patients in house who smoke, and what they did for each patient, and provided it to the surveyor team. The survey team reviewed a sample of those records to verify implementation before lifting the IJ that same day.


Cross reference
482.13(c)(2) Patient Rights: Care In Safe Setting

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure adequate no smoking signage in patient rooms and areas oxygen was administered; failed to adequately assess and identify patients who smoke and the need to secure smoking materials; failed to educate patients regarding the dangers of smoking and oxygen use for one of one medical record reviewed (MR1); and failed to encourage patients who smoke alternatives to smoking while admitted to the facility (A0144).

Findings:

Review on January 24, 2025, of the facility policy, "Tobacco-Free Environment Policy, 200.88," last reviewed February 2, 2023, revealed "... Purpose To set forth the policy for maintaining a tobacco-free environment to promote the safety, health, and wellness of all patients, employees, volunteers, faculty members, medical staff, students, vendors, and visitors of ... TJUH System and its Subsidiaries. ... Scope This policy applies to all Jefferson patients, visitors, vendors, students, volunteers, medical staff and employees within fifty (50) feet of the entryway to or exit from any property owned, rented or leased by Jefferson; ... Procedure I. Definitions A. Smoking is defined as the use of or carrying of a lighted cigarette, cigar, pipe, or other tobacco product. It means inhaling, exhaling, burning, or carrying any lighted or heated cigarette, cigar, or pipe. ... II. Tobacco-Free Environment A. Guidelines 1. Smoking of the use of tobacco products/smoking material is not permitted anywhere on the Jefferson Campus. 2. Patients are informed of this policy upon registration, arrival, or as soon thereafter as is reasonably possible. B. Notification 1. Signage prohibiting smoking shall be posted to notify individuals visiting the Jefferson Campus of this Tobacco-Free Environment Policy. ..."

Review on January 24, 2025, of MR1 revealed the patient was admitted to the facility on January 21, 2025, for lower extremity numbness and weakness secondary to medistinal mass with adjacent destructive vertebral changes. There was documentation the patient reported smoking a few cigarettes a day. There was a physician order dated January 21, 2025, for Nicorette (a medicine used for nicotine replacement therapy) 2 milligrams lozenge by mouth as needed every two hours. There was no documentation MR1 was offered or administered the Nicorette lozenge. There was no documentation MR1 was assessed for having smoking materials on their person. There was no documentation MR1 ' s smoking materials were secured by the facility.

Continued review of MR1 revealed nursing documentation dated January 23, 2025, the nurse responded to MR1's bed alarm, opened the door, and immediately smelled burning smoke in the room. There were burns/holes in the bed sheets. MR1's nasal cannula was sitting on the patient's lap. There was documentation half of the nasal cannula was burned off and a lighter was found in the patient's bed. There was documentation MR1 admitted to attempting to light a cigarette, felt something catch on fire, and put it out with a pitcher of water. There were new burn marks to patient's chest, upper lip, and nose. MR1's vital signs were stable and there was no shortness of breath. There was documentation MR1's primary care team was called to the bedside. There was documentation security completed a room search and all belongings were sent home with the patient's brother who had arrived after the incident.

Continued review of MR1 revealed physician documentation dated January 23, 2025, MR1 sustained first/second degree partial thickness burns to face and neck after MR1 attempted to smoke in the hospital while on six liters of oxygen via nasal cannula. There was documentation MR1 was evaluated. There was documentation there was no overt airway compromise and MR1 was transferred to the Surgical Intensive Care Unit (SICU) overnight for airway monitoring. There was documentation MR1's burns were cleansed and Bacitracin and Silvadene were applied.

Continued review of MR1 revealed there was no documentation MR1 was educated on the dangers of smoking while being administered oxygen prior to attempting to smoke while receiving oxygen on January 23, 2025.

Interview on January 24, 2025, with EMP3, at approximately 1700 confirmed the above findings.

An observation tour of the 9th floor Comprehensive Spine nursing unit was completed on January 24, 2025, at approximately 1700. There were no visible no smoking signs in the patient rooms where oxygen was accessible and administered.

Interview on January 24, 2025, with EMP4, at approximately 1705 confirmed the above findings.

On January 27, 2025, the State Survey agency confirmed the issue related to the posting of non-smoking signs was addressed, and on February 5, 2025, the facility identified patients in-house who smoke with interventions provided for each of these patients.