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Based on the nature of standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.641, Periodic Evaluation and Quality Assurance Review, was out of compliance.

C-0336 - Standard: Quality Assurance - The CAH has an effective quality assurance program to evaluate and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes. The program requires that--

Based on interviews and document reviews, the facility quality program failed to ensure a process change was in place for staff to be able to manage a patient's behavior until discharge, after the facility identified an incident in which the patient harmed herself while smoking with oxygen. This failure occurred in one of six swing bed records reviewed (Patient #3).

Findings include:

Facility policies:

The Quality Management Plan read, the Quality and Patient Safety plan provides an integrated and comprehensive program to monitor, assess and improve the quality and safety of patient care delivered. Initiatives are designed to minimize risks and hazards of care. Guiding Principles include, establish a culture to prevent inadvertent harm to patients as a result of our care. This culture focuses on safety where we openly report mistakes and take action to make improvements in our processes.

The Resident Behavior and Facility Practices- Extended Care policy read, it is the policy of the facility to provide a living situation that follows established policies and procedures when dealing with residents who present behavior problems. Behavioral plan is written as part of the overall plan of care. Common behavioral problems includes smoking. A significant change in the resident's condition or failure of the plan to effect behavior change should trigger an early review. Guidelines for dealing with resident rights conflicts include, resident rights may be limited when it places the resident or others at risk, and in extreme instances the right may be limited indefinitely.

The Tobacco Free Campus policy read, the facility is a tobacco free campus. Department managers enforce the regulations. There are no smoking areas on campus for patients or visitors.

The Patient/ Resident Bill of Rights and Responsibilities read, patients have the right to a secure and safe environment. Personal Property policies include, the resident has the right to retain and use personal possessions as long as items do not conflict with fire and/or safety codes, policies and regulations. Facility has the right to limit this right on ground of space, health or safety.

The Risk Management Occurrence Reporting policy read, an incident/ occurrence is any event or situation that is not consistent with the routine operation of a facility and that adversely affects or threatens to affect the well-being of the employees, patients, casual workers, volunteers, students or visitors at the hospital. All Occurrence Reports will be followed up on and tracked for resolution.

1. The facility's staff failed to evaluate and implement corrective action through the facility's quality management process after a patient harmed herself while smoking with oxygen.


a. A review of Patient #3's medical record for admission dates 1/11/19 to 1/14/19 was conducted.
On 1/14/19 at 1:31 p.m., Registered Nurse (RN) #4 documented in a nursing note, the patient was found outside sitting on her walker, with her face blackened and the nasal cannula of her oxygen melted. The patient was taken to the Emergency Department (ED) to be evaluated.

A review of an internal reporting document, dated 1/14/19, was conducted. The report's Description of Event read, on 1/14/19 at approximately 2:00 p.m. an off-duty employee came into the hospital to inform staff Patient #3 was outside and had burns on her face. Patient #3 was brought inside, had black charring widespread on her face, and the nasal cannula was melted with plastic melted to the patient's nares.

The director of nursing (Director #3) documented in the report, she was aware of the event shortly after it happened and saw Patient #3 while she was in the ED. Director #3 wrote the patient reported she was lighting a thread on her hat, but later stated she was smoking a cigarette when the event occurred. Patient #3 had been on a safety contract prior to the event, due to dangers of her smoking. The social worker also had been involved with the patient and her family to help with cessation, which both interventions had failed.

Director #3 further documented in the report, a care conference was held on 1/15/19, during which Patient #3 stated she did not wish to quit smoking and family agreed the patient was not safe to be unsupervised while smoking. The patient and family agreed for her to be placed in a facility where she could smoke in a supervised area so further safety incidents would not occur. The occurrence was closed on 1/24/19. The report did not indicate whether other interventions to address Patient #3's safety were discussed or implemented.

b. On 6/5/18, six months prior to Patient #3's incident, the Smoke Free Addendum to Extended Care Rights Policy was signed by Patient #3, the Inpatient Nursing Director at the time and Social Work Case Manager #6. The addendum read, the purpose of the addendum was the facility's desire to mitigate (iii) the increased risk of fire from smoking. The resident acknowledged the premises of the facility had been designated a smoke-free living environment for Extended Care Residents. The resident agreed to not smoke anywhere in the building, or the adjourning grounds of the building, or other parts of the community. A breach of the agreement gave the facility the right to evict the resident at the facility's Extended Care Unit. There were no second chances to this agreement, and the agreement served as the resident's final warning.

c. Review of Patient #3's medical record, from 1/14/19 to 2/7/19 was conducted.

On 1/15/19 at 3:33 p.m., Patient #3's RN documented a care conference occurred. The meeting addressed Patient #3's right to smoke, but the patient was informed the facility was non-smoking and could not keep her safe if she continued to smoke. The patient was informed staff could not go out with her and ensure she was safe.

On 1/15/19 at 4:13 p.m. Social Work Case Manager (CM) #6 documented a care conference occurred with Patient #3, her family, DON #3, the patient's RN, the patient's physician, and the social worker. CM #6 wrote the meeting addressed Patient #3's safety and concerns regarding her smoking with oxygen. The meeting reviewed prior interventions and education. The outcome of the meeting was patient would be transferred to a different facility able to monitor her smoking, as the facility could not provide this supervision due to staff capacity.

Although, Both CM #6 and RN # discussed prior interventions and education at the care conference, neither staff member indicated how the patient's care plan was adjusted in order to keep Patient #3 safe while she remained at facility.

Review of the nursing notes revealed Patient #3 was allowed to continue to smoke while she remained at the facility. There was no evidence in the nursing notes that indicated Patient #3 was supervised or accompanied during the times she was outside.

As example, on 1/21/19 at 5:54 p.m., RN #7 documented the patient was outside, off hospital property several times smoking cigarettes.

On 1/29/19 at 1:03 a.m. RN #8 documented Patient #3 was keeping to her evening routine of going outside to smoke at 6:00 p.m. and returning at 6:20 p.m.

On 1/30/19 at 1:36 a.m. the patient's RN documented Patient #3 returned to the facility at 6:45 p.m., after the patient went for a walk and cigarettes.

On 2/2/19 at 1:21 p.m. RN #4 documented the patient had been out to smoke several times this day, and the patient reported she was turning her oxygen off while smoking. However, there was no evidence in nursing notes documented on 1/21/19, 1/29/19, and 1/30/19, which showed staff observed the patient without oxygen while smoking.

d. On 8/14/19 at 10:16 a.m. an interview with RN #4 was conducted. RN #4 stated staff used to go outside to monitor the patient while she was smoking, but this was a hardship for staff and so the contract was implemented.

RN #4 stated she was present when the event occurred where in Patient #3 was burned while smoking with her oxygen on. RN #4 stated on the day of the event, Patient #3 was found sitting on a bench outside of the facility by a travel RN coming to work, and she was brought to the ED immediately for evaluation. RN #4 stated Patient #3 was treated in the ED for superficial injuries and blistering around her lips and nose, she was evaluated for any airway complications, and was discharged back to her extended care bed at the facility.

RN #4 stated she believed the event occurred about a block away from the hospital and then the patient walked back to where she was found.

RN #4 stated her supervisors were notified immediately after the event. She stated there were discussions regarding Patient #3's safety contract, and the decision was made to look for placement in a new facility. RN #4 stated there were no changes made to staff monitoring for the patient or to facility policies. She stated she did not witness Patient #3 smoking after the event but the patient probably could have as she was still allowed to leave the facility.

e. On 8/14/19 at 11:06 a.m., an interview with RN #5 was conducted. RN #5 stated Patient #3 was a resident at the facility who was a known smoker, and she heard about an event wherein the patient smoked with her oxygen on and her face caught fire. RN #5 stated she was not present when the event occurred but heard the patient had left and smoked, and stated she saw injuries to the patient's face after the event. RN #5 stated she could not remember whether any changes were made or education provided to staff following this event.

RN #5 stated there was no smoking allowed on the grounds of the hospital. RN #5 stated if a patient or resident who used oxygen requested to leave and smoke, it would not be acceptable due to the risk of fire, ignition, combustion of the oxygen, or an individual not being able to breathe without oxygen.

f. On 8/15/19 at 12:42 p.m., an interview with Vice President of Nursing (VP) #1 and Director #3 was conducted. Both stated they were notified and involved in the investigation of the event wherein Patient #3 was burned while smoking with oxygen. VP #1 stated there were on-going discussions prior to the event regarding monitoring Patient #3 when she smoked, and stated the process was for staff to accompany the patient and make sure she was safe.

Director #3 stated the patient's smoking was a danger as evidenced by this and prior events, and stated the danger prompted the contract to be implemented. She stated in the past staff would go with the patient and encouraged the patient to wait to go outside until staff could accompany her, however staff also needed to attend to the unit and they could not stop her if she chose to leave without staff supervision.

Director #3 stated after the event there was a care conference conducted with Patient #3 and family wherein staff expressed concerns with patient's safety and her need for a facility that could supervise her smoking. Director #3 said Patient #3 expressed she did not want to quit smoking. DON #3 stated, because the patient wished to continue smoking, the facility could not keep the patient safe and could not prevent a similar event from occurring. She then said after the event the patient started smoking more. Director #3 stated the facility had attempted daily management of the patient's smoking from the beginning and there was not much more the staff could do aside from constant encouragement and reminders.

VP #1 stated after the event, staff continued previous interventions of supervising and educating Patient #3, reminders not to smoke, and taking her cigarettes away, however she could not state where these interventions were documented and stated she did not have notes regarding these discussions. VP #1 stated it was documented by Patient #3's physician the patient had failed smoking cessation and so she would be transferred to another facility. She stated staff had exhausted their resources to keep the patient safe prior to the event, and after the event they continued to do more of the same.

Based on interviews and document review, the facility failed to provide medically-related social services to meet a patient's communication needs, specifically to ensure a patient's hearing aids were repaired and functioning in one of two swing bed records reviewed for patients who required communication devices (Patient #3).

Findings include:

Facility policies:

The Social Work for Extended Care Patients policy read, it is the policy of the facility to assess for and provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Medically-related social services means services provided by the facility's staff to assist residents in maintaining or improving their ability to manage their everyday physical, mental and psychosocial needs, which may include making arrangements for obtaining needed adaptive equipment. Factors with a potential negative effect on well-being include need for hearing services.

The Interpretation Services and Adaptive Communication policy read, when an individual is identified or self-identifies as a person with a disability that affects her/ his ability to communicate, staff will determine what equipment and aids are necessary to provide effective communication. The provider will obtain equipment and aids as needed to assist the person.

1. The facility failed to ensure a patient's hearing aids were repaired and functioning in order to meet the resident's communication needs.

a. A review of Patient #3's medical record for admission dates 1/1/19 to 1/14/19 was conducted. The History and Physical (H&P) dated 1/1/19 at 3:23 p.m. read, Patient #3's hearing was noted to be decreased because hearing aids were not working well. The patient's RN documented on the same date the patient's hearing aids were not working well enough.

On 1/4/19 and 1/8/19 the RN (Registered Nurse) Simple Assessment flowsheet read, Patient #3 had "moderately impaired hearing" in both right and left ears. The notes did not indicate whether interventions to address Patient #3's decreased hearing and non-functioning hearing aids were planned or implemented.

On 1/7/19 at 5:19 p.m. Social Work Case Manager #6 documented she assisted Patient #3 to call Medicare to change her prescription drug plan, because the patient was hard of hearing.

b. A review of Patient #3's medical record for admission dates 1/14/19 to 2/7/19 was conducted.

On 1/15/19 at 3:20 p.m. the patient's RN documented in the nursing notes a care conference occurred. The note read, Patient #3 did not have her hearing aids as they were out being serviced. It was difficult for Patient #3 to hear what was said during the care conference, and the discussion was repeated for her so she understood. Social Work Case Manager #6 was noted to be present during this care conference.

Social Work Case Manager #6 documented clinical notes on multiple dates (1/15/19, 1/16, 1/21, 1/22, 1/23, 2/1, 2/4, 2/5 and 2/7). Social Work Case Manager #6's notes did not indicate whether interventions to address Patient #3's decreased hearing and non-functioning hearing aids were planned or implemented.

On 2/4/19 at 2:37 p.m. the patient's RN documented Patient #3 requested batteries for her hearing aids. The RN wrote a note to the patient, as the patient was unable to hear, informing her that her hearing aids were not fixed and batteries would not make them start working.

c. On 8/15/19 at 12:11 p.m. an interview with RN Case Manager #2 was conducted. RN Case Manager #2 stated she was responsible to make any needed referrals for extended care patients, such as referrals to arrange equipment. RN Case Manager #2 stated when adaptive equipment was needed, nursing staff informed her or the nursing manager and sometimes would send the initial order, and she followed to ensure equipment was in place.

RN Case Manager #2 stated she was not the case manager at the time Patient #3 was a patient at the facility, but she was aware Patient #3's hearing aids did not work and stated the hearing aids needed to be repaired rather than needing new batteries. RN Case Manager #2 stated if a patient could not hear without hearing aids, this would impact a patient's ability to communicate and staff would have to write things down to communicate with the patient.

RN Case Manager #2 stated the nursing manager at the time and possibly Social Work Case Manager #6 were assisting to get Patient #3's hearing aids repaired. She stated the nursing manager was going to mail Patient #3's hearing aids to be repaired, but she did not recall whether this was done. RN Case Manager #2 stated it was the facility staff's responsibility to assist with this matter. She stated the nursing manager or director would always be notified of a need for adaptive equipment and this person was responsible to ensure steps were taken to address the need.

d. On 8/15/19 at 12:40 p.m. an interview with Vice-President of Nursing (VP) #1 and Director of Nursing (Director #3) was conducted. VP #1 stated the nursing director who managed the inpatient unit during the time Patient #3 was a patient at the facility would have been involved with getting the patient's hearing aids repaired. Director #3 stated she and the case manager were always involved in conversations regarding a patient needing adaptive equipment, which included dentures, hearing aids and glasses.

Director #3 stated the process to assist with obtaining adaptive equipment would be to involve the family and multi-disciplinary team, and to determine whether there was any cost and where the equipment would be sent for repairs. Director #3 stated this would be documented in a patient's chart. She stated the case manager would be responsible to ensure follow-up, tracking, and responding in a timely manner. Neither VP #1 nor Director #3 could state whether Patient #3's hearing aids were repaired.