Mosholu Parkway Nursing & Rehabilitation Center

Deficiency Details, Complaint Survey, April 12, 2011

PFI: 1236
Regional Office: MARO--New York City Area

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F323 483.25(h): FACILITY IS FREE OF ACCIDENT HAZARDS

Scope: Widespread

Severity: Immediate Jeopardy

Substandard Quality of Care

Corrected Date: May 11, 2011

The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Citation date: April 12, 2011


Based on observations, interviews, and record review the facility failed to implement appropriate policies and procedures related to resident smoking practices, failed to adequately assess/reassess residents for safe smoking behaviors and failed to provide adequate supervision for residents that smoke. Specifically, a resident who was a known, unsafe smoker sustained burns over 60% of his body after an accident that occurred while he was smoking unsupervised in the smoking room. The resident was hospitalized and is in critical condition.

This was evidenced in 4 of 14 sampled residents (Resident #1). These deficient practices have the potential of affecting all residents in the facility, whose safety from fire hazards is compromised.

This resulted in serious physical harm to one resident (Resident #1), psychological harm to 3 residents (Residents #10, #12 and #14) and the potential for serious harm to the health and safety of all residents in the facility, that is Immediate Jeopardy and Substandard Quality of Care.

Complaint # NY00099858

The findings are:

The facility Smoking Program policy with a revision date of 5/2010 was reviewed. Page three (3), paragraph one (1) of the policy states that residents cannot, under any circumstances, have their own matches, lighters or any other smoking material in their possession. Paragraph four (4) of the policy states that cigarettes that are purchased for residents by family members are to be kept in a locked box in the Quiet Room (also known as the smoking room).

Smoking Restrictions are listed on page four (4) of the policy. Restriction #5 states that smoking shall not be permitted in the quiet room (smoking room) without the direct supervision of a responsible staff member, and direct supervision must be provided throughout the entire smoking period. Restriction #6 states that the classification of residents as either responsible or hazardous smokers shall be made at least quarterly by the Director of Nursing, Attending Physician and the Interdisciplinary Team.

On page six (6) of the policy, under the title "Identification of Smokers/Hazardous Smoker," it states that an initial admission interview of a resident is carried out by the Social Services Department. This information will be communicated to the nursing unit and the charge nurse on the unit will be responsible for including "smoking" information in the nursing admission assessment, CNA assignment sheets, and nursing care plan. Further identification of smoking habits will be ascertained at the IDC meeting and an individual plan of care will be developed for each resident. All identified smokers will be referred to the Safety Committee Coordinator, who will be responsible for distributing a list of all smokers/hazardous smokers to all departments and for updating the list as needed.

Resident #1 is a 56 year old male admitted to the facility on 4/6/06 with diagnoses including Schizo-affective Disorder, Psychosis and Paraplegia. The Minimum Data Set 3.0 with an assessment reference date of 11/17/2010 identifies the resident with moderately impaired cognition.

A Hazardous Smoking Assessment was last completed on 10/10/06. The form did not include an explanation of the outcome of the assessment.

A Smoking Regulation Agreement was signed by the resident on 7/1/10. The agreement listed the smoking regulations. The regulations included residents not being allowed to have their own smoking materials and that cigarettes will be distributed and lit "as required in the (smoke) room by staff for residents assessed as hazardous smokers."

A Social Service note dated 7/8/10 documented that the resident "is a smoker although he states that he stopped smoking a year ago. Resident has been seen smoking the leftover cigarette butts."

The resident has no care plan with planned interventions for smoking.

The Hazardous Smoking Assessment form was reviewed. It documented that residents who smoke will be assessed on admission, quarterly, and episodically for their ability to smoke safely. Each assessment will be brought to the interdisciplinary team meeting in order to discuss, evaluate and develop appropriate care plan interventions. Areas of assessment include: places ashes in ashtray; extinguishes cigarettes in ashtrays; places used cigarette butts in the mouth; difficulty bringing hand to mouth (i.e. contractures, tremors); accepts redirection; will wear smoking aprons; places cigarette butts in pockets; lights cigarettes of other residents; and gives cigarettes to other residents.

A list of "Residents Who Smoke" was supplied by Recreation Aide #3 on duty on 4/10/11 at 12:15 PM. The list contained a total of 14 names with four (4) of them crossed off. Seven (7) of the residents are identified as unsafe smokers including Resident # 1. There was no date on the list.

The Recreation unit (6th floor) was observed on 4/10/11 at 12:00PM. The smoking room (also known as the quiet room) was noted to the left of the elevator. It is an enclosed room with a large window approximately 4 feet by 3 feet. The facility's recreation room is located on the other side of the window. The door also has a window.

The facility video surveillance was viewed on 4/10/2011 at 12:30 PM. There is no staff member seen on the video on 4/9/11 at 4:34:11 PM providing direct sight supervision in the smoking room or in the recreation room, where there are more than 25 residents present.

Resident #1 was observed wheeling himself toward the recreation office, at the far end of the floor, at 4:34:41. He is then seen wheeling back towards the smoking room at 4:36:01 only to return back towards the office at 4:37:04. He is then observed wheeling back in the direction of the smoking room at 4:39:16. There is no staff member with him, behind him, or anywhere around him. He enters the smoking room and pulls out matches from his pants at 4:39:31 and lights a cigarette. He places the used match on the side of his wheelchair seat on what appears to be a white sheet and positions himself against the wall of the smoking room at 4:40:39. There is only partial view of the resident on the video surveillance at this point. Only the lower portions of his legs and wheelchair are visible.

Review of cameras #2, 4, 5, and 6 reveal that there is no staff monitoring the residents in the recreation room or in the smoking room at this time. At 4:44:57, Recreation Aide #1 is observed walking from the recreation office to the staff bathroom, which is halfway between the recreation office and the smoking room. Resident #1 has now been in the unsupervised smoking room for a total of five (5) minutes.

At 4:45:01 the first visual of Resident #1 on fire is noted on the video. It is uncertain as to when the fire actually started as he has been smoking for five (5) minutes, without supervision, and there is only partial view of the resident on the recording up to this point. At 4:45:27 Resident #11, seated at a table outside the smoking room, is seen pointing towards the smoking room. Resident #10 reacts in the same manner, while Resident #14 is seen wheeling himself towards the smoking room. Recreation Aide #1 is observed coming out of the bathroom at 4:45:48 and runs towards the smoking room. Recreation Aide #2 is observed running from the recreation office towards the smoking room at 4:46:02.

Recreation Aide #1, on duty on 4/9/11 during the 12:30PM to 8:30 PM shift, was interviewed on 4/11/11 at 7:30 PM. She stated that she had just finished giving cigarettes to other residents and Resident #1 came to her and said that he needed a match. She went back to the office to get matches from her co-worker and when she returned, the resident was already on fire. The surveyor informed the Recreation Aide that she was observed on video in the recreation office area and that she was then observed going into the bathroom and, following that, towards the smoking room. She stated that she did not recall anything other than going to get matches and returning to find the resident on fire. She stated that she was assigned to monitor the smoking room that day and that she did not leave the room unattended. She further stated that there was no one in the smoking room and she just went to get matches.

Recreation Aide #2, on duty on 4/9/11 during the 9:00 AM to 5:00 PM shift, was interviewed on 4/12/11 at 12:05 PM. She stated that Resident #1 came up at 4:30 PM and was asking for cigarettes. Recreation Aide #1 gave Resident #1 a cigarette and then came back to the office to get matches. Recreation Aide #2 stated that she responded when she heard residents in the recreation room screaming.

The Medical Director was interviewed on 4/11/11 at 9:30AM and 12:30 PM. He stated that Resident #1 was listed in critical condition with burns to 60 percent of his body, including his legs, groin, trunk and arms. The resident was intubated and had a central line placed. The Medical Director stated that he signed the smoking policy but was not really involved in its development. He stated that the residents require supervision while smoking and that all smokers are considered unsafe. The Medical Director stated that he was not involved in the evaluation of the smoking policy because the new policies were doing well.

Observations were conducted during three (3) separate smoking sessions in the smoking room on the 6th floor.

On 4/10/11 between 4:05PM and 4:30PM there was one (1) recreation aide observed with 4 boxes of cigarettes in a plastic container. There were also various lighters and matches in the plastic container. During the observation this aide, who was assigned to monitor the smoking room, did not enter the smoking room at any time. She was observed outside of the smoking room, talking to other residents in the recreation area. From time to time, the aide would observe the smokers in the smoking room through the window that looked into the smoking room from the recreation area. The aide was not in the line of sight with the residents in the smoking room for the entire duration of the smoking session. At one point there were eight (8) individuals smoking in the room, including Resident #14. He was seated in his wheelchair. He lit his cigarette with a set of matches that he pulled out of his own personal belongings and did not relinquish his matches to the recreation aide when he left the smoking room. The aide did not approach him or ask for his lighting materials. Resident #14 was also observed dropping the ash of his cigarette on the floor and lighting another resident's cigarette from his lit cigarette. Resident #6, who had hand tremors, was observed having his cigarette lit by another resident's cigarette. Resident #7 was observed smoking his cigarette down to the butt. Resident #2 had two cigarettes lit at one time. He was observed smoking his cigarettes down to the butt. Resident #3 was observed smoking her cigarette down to the butt. Her cigarette was lit by another resident. The aide did not intervene or address issues that were observed during the smoking session.

Another observation of the smoking room was conducted on 4/10/11 between 6:00PM and 6:40 PM. A newly-hired staff member (CNA) was assigned to the smoking room on that day. The Director of Maintenance was observed instructing her on how to monitor the smoking room. A total of eight (8) residents were observed entering the smoking room with their own cigarettes. During the smoking session it was noted that the assigned staff member was not in the direct line of sight of the smoking room or directly monitoring the residents who were smoking. She was observed standing 2-3 feet away from the smoking room. Resident #7 announced that he had his own cigarette in his pocket; he was also observed smoking his cigarette down to the butt. The CNA did not intervene or address issues during the smoking session.

A third observation of the smoking room was conducted on 4/11/11 between 9:30AM and 10:00AM. An aide was assigned to monitor the smoking session. She was standing approximately six (6) feet from the door/window to the smoking room. She was observed attending to other residents (non-smokers) who were located in the recreation room. At one point, there were nine (9) residents in the smoking room. A resident was observed bringing in her own lighter and lighting cigarettes for other smokers. A second resident was observed with his own lighter. Residents were observed lighting each others' cigarettes. Resident #6 and Resident #7 were observed sharing the same cigarette. Resident #6 was observed with hand tremors. Resident #7 was noted placing a cigarette butt in his pocket. Resident #14 was noted with his own matches.\i At one point, the aide inquired whether a resident had dropped their cigarette on the floor. Although there was no reply to her inquiry, she did not go in the room to investigate whether or not the cigarette was burning on the floor. She did not intervene or address issues that were observed during the smoking session.

On 4/11/11 at 9:50AM an interview was conducted with the Recreation Aide that monitored the 9:30 AM to 10:00 AM session on 4/11/11. The recreation aide stated that she gives out cigarettes. Her responsibility is to make sure that the residents are safe and do not get into fights or fall. She stated that Resident #3 is considered a hazardous resident because she is unsteady in her gait. She identified another resident as an unsafe smoker, stating that he was unsafe due to risk for falls. The recreation aide could only identify two unsafe smokers. She did not indicate that she observes for any other smoking hazards. She stated that she does not report any smoking behaviors to social work. The Recreation Aide stated that some residents carry their own cigarettes because they are more alert or the family provides the cigarettes. When asked why she did not question residents with their own cigarettes or confiscate the cigarettes, she stated that it was not uncommon for residents to carry their own cigarettes.

Resident #2 is a 66 year old male admitted to the facility on 3/9/11 with diagnoses including Seizures, Chronic Obstructive Pulmonary Disease, Paranoid Schizophrenia, and Glaucoma. The MDS 3.0 with an assessment reference date of 3/16/2011 identified the resident as cognitively intact.

The Admission Nursing Evaluation dated 3/9/11 documented that the resident is a smoker. He had a safe smoking care plan dated 3/10/11 which states that the resident will abide by all smoking rules. Interventions include resident will be assessed on cognitive ability to smoke safely, explain terms of smoking contract to the resident, monitor smoking for 5 days for "new" resident for safe smoking, discuss on-going status with team, and monitor on-going smoking practice per nursing policy. A smoking contract was signed by the resident on 3/10/11.

Nursing notes on 3/10/11 state he is very confused and paranoid. On 3/11/11 and 3/1211 he is noted to be non-compliant with medications. On 3/19/11 it is noted that he refused to listen to nurses and aides and continues to pick up hot cups of coffee. There is no smoking assessment in the medical record and he is not listed on the Smoker's list provided.

Resident #3 is an 80 year old female admitted to the facility on 12/22/08 with diagnoses including Dementia, Schizophrenia, and Chronic Obstructive Pulmonary Disease. The MDS 3.0 with an assessment reference date of 3/4/11 documented that the resident was unable to complete the BIMS and had long term memory impairment.

The Admission Nursing Evaluation dated 1/18/11 (on readmission) documented that the resident is a smoker. She is listed on the smoker list as hazardous. Nurse's notes dated 12/14/10 stated that the resident was noted with cigarettes (3 small unlit used butts and 2 empty match cards). A room search was done. In a nurse's note on 12/16/10 at 3AM, it was reinforced not to smoke on the unit and stated "I smoke anywhere I want to." No cigarette or matches found on her. There is no smoking assessment and smoking care plan in the medical record. She is listed on the smoker list as hazardous.

Resident #6 is a 63 year old male admitted to the facility on 11/19/10 with diagnoses including Schizophrenia and Alzheimer's Disease. The MDS 3.0 with an assessment reference date of 2/17/11 identified that the resident has moderately impaired cognition.

The Admission Nursing Evaluation dated 11/19/10 identified the resident as a smoker. The resident had a safe smoking care plan which was initiated on 11/23/10. Interventions include monitoring smoking for 5 days for "new" resident for safe smoking, and monitor on-going smoking practice per nursing home policy. There are no evaluation notes on the care plan. Social Service note dated 12/7/10 documented that the resident is a smoker and is not safe. ( "and is not safe" is crossed out and initialed by the social worker). A smoking contract was signed by the resident on 11/23/10. There is no smoking assessment. The resident is not listed on the smoker's list. The resident was observed during a smoking session on 4/11/11 at 9:30 AM with tremors.

Additionally, Residents #4, 5, 7, 8, 9 and 14 did not have any smoking assessments in the medical record. Residents #1, 5, 8, and 9 did not have any smoking care plans and Residents #8 and 9 were not listed on the smokers' list supplied.

On 4/10/11 at 6:05 PM an interview was conducted with an LPN on Resident #2's unit. The LPN stated that he is not familiar with smokers on his unit and is not aware of a list of smokers.

On 4/11/11 between 6:45AM and 6:50 AM two CNAs working on Resident #6's unit were interviewed. Neither CNA were able to identify the hazardous smokers on their unit nor were they aware of a facility list of known smokers.

On 4/10/11 at 5:55 PM an interview was conducted with an LPN on Resident #3's unit. The LPN stated that she does not know who the smokers are on that unit. She stated that there is no current list of smokers.

The Social Worker was interviewed on 4/11/11 at 9:50 AM. She stated that she meets with the residents upon admission and asks them if they are smokers. If they reply that they smoke, she reviews the smoking contract with them and initiates a care plan. She stated that if staff report concerns about a resident's smoking habits to her, she will change the care plan to indicate that the resident is an unsafe smoker. She stated that Social Services is not involved with the Hazardous Smoker Assessment and does not know who is responsible for completing it. .

The Director of Nursing (DON) was interviewed on 4/11/11 at 7:55 AM. She stated that the Recreation Department is primarily responsible for the smoking program. She stated that some residents who are alert can go up to smoke at any time and are categorized as safe smokers. A Hazardous Smoker Assessment is completed by Social Services through interview. Nursing is only involved if residents do not follow the facility policy, such as smoking in their room or bathroom. The DON stated that a care plan is initiated by nursing if there are any behaviors noted. She stated that Social Services, in conjunction with the Recreation Department, is responsible for identifying and reporting smoking behaviors to nursing. She stated that cognitive impairment and tremors are examples of behaviors that can make a resident an unsafe smoker. The DON stated that the Recreation Department is responsible for generating the smokers list and updating it after interdisciplinary meetings are held and when there are new admissions.

The Safety Coordinator/ Housekeeper was interviewed on 4/11/11 at 10:05 PM. He stated that he does not generate or update the smoker list. He believes that Director of Nursing generates the list because she heads the Safety Committee Meeting every month. The committee meets every month and consists of all the department heads.

The Director of Recreation was interviewed on 4/11/11 at 11:05 AM. She stated that Recreation Aides are responsible to monitor the smoking room. She is aware that the Aides keep their distance from the smoking room when monitoring because the aides do not want to be exposed to second-hand smoke. She further stated that administration is aware of this. Because of the second-hand smoke issue, aides refuse to light residents' cigarettes. Instead, a match/lighter is handed to an alert resident, who will light cigarettes for other residents. The Director of Recreation stated that she is responsible for generating the smoker list based on who is logged-in as a smoker and upon any new admissions. Only residents who come up to smoke are logged in the book.

415.12(h)(1)(2)

Citation date: April 19, 2011

Based on observations, interviews, and record review the facility failed to implement appropriate policies and procedures related to resident smoking practices, failed to adequately assess/reassess residents for safe smoking behaviors and failed to provide adequate supervision for residents that smoke. Specifically, a resident who was a known, unsafe smoker sustained burns over 60% of his body after an accident that occurred while he was smoking unsupervised in the smoking room. The resident was hospitalized and is in critical condition.

This was evidenced in 4 of 14 sampled residents (Resident #1). These deficient practices have the potential of affecting all residents in the facility, whose safety from fire hazards is compromised.

This resulted in serious physical harm to one resident (Resident #1), psychological harm to 3 residents (Residents #10, #12 and #14) and the potential for serious harm to the health and safety of all residents in the facility, that is Immediate Jeopardy and Substandard Quality of Care.

Complaint # NY00099858

The findings are:

The facility Smoking Program policy with a revision date of 5/2010 was reviewed. Page three (3), paragraph one (1) of the policy states that residents cannot, under any circumstances, have their own matches, lighters or any other smoking material in their possession. Paragraph four (4) of the policy states that cigarettes that are purchased for residents by family members are to be kept in a locked box in the Quiet Room (also known as the smoking room).

Smoking Restrictions are listed on page four (4) of the policy. Restriction #5 states that smoking shall not be permitted in the quiet room (smoking room) without the direct supervision of a responsible staff member, and direct supervision must be provided throughout the entire smoking period. Restriction #6 states that the classification of residents as either responsible or hazardous smokers shall be made at least quarterly by the Director of Nursing, Attending Physician and the Interdisciplinary Team.

On page six (6) of the policy, under the title "Identification of Smokers/Hazardous Smoker," it states that an initial admission interview of a resident is carried out by the Social Services Department. This information will be communicated to the nursing unit and the charge nurse on the unit will be responsible for including "smoking" information in the nursing admission assessment, CNA assignment sheets, and nursing care plan. Further identification of smoking habits will be ascertained at the IDC meeting and an individual plan of care will be developed for each resident. All identified smokers will be referred to the Safety Committee Coordinator, who will be responsible for distributing a list of all smokers/hazardous smokers to all departments and for updating the list as needed.

Resident #1 is a 56 year old male admitted to the facility on 4/6/06 with diagnoses including Schizo-affective Disorder, Psychosis and Paraplegia. The Minimum Data Set 3.0 with an assessment reference date of 11/17/2010 identifies the resident with moderately impaired cognition.

A Hazardous Smoking Assessment was last completed on 10/10/06. The form did not include an explanation of the outcome of the assessment.

A Smoking Regulation Agreement was signed by the resident on 7/1/10. The agreement listed the smoking regulations. The regulations included residents not being allowed to have their own smoking materials and that cigarettes will be distributed and lit "as required in the (smoke) room by staff for residents assessed as hazardous smokers."

A Social Service note dated 7/8/10 documented that the resident "is a smoker although he states that he stopped smoking a year ago. Resident has been seen smoking the leftover cigarette butts."

The resident has no care plan with planned interventions for smoking.

The Hazardous Smoking Assessment form was reviewed. It documented that residents who smoke will be assessed on admission, quarterly, and episodically for their ability to smoke safely. Each assessment will be brought to the interdisciplinary team meeting in order to discuss, evaluate and develop appropriate care plan interventions. Areas of assessment include: places ashes in ashtray; extinguishes cigarettes in ashtrays; places used cigarette butts in the mouth; difficulty bringing hand to mouth (i.e. contractures, tremors); accepts redirection; will wear smoking aprons; places cigarette butts in pockets; lights cigarettes of other residents; and gives cigarettes to other residents.

A list of "Residents Who Smoke" was supplied by Recreation Aide #3 on duty on 4/10/11 at 12:15 PM. The list contained a total of 14 names with four (4) of them crossed off. Seven (7) of the residents are identified as unsafe smokers including Resident # 1. There was no date on the list.

The Recreation unit (6th floor) was observed on 4/10/11 at 12:00PM. The smoking room (also known as the quiet room) was noted to the left of the elevator. It is an enclosed room with a large window approximately 4 feet by 3 feet. The facility's recreation room is located on the other side of the window. The door also has a window.

The facility video surveillance was viewed on 4/10/2011 at 12:30 PM. There is no staff member seen on the video on 4/9/11 at 4:34:11 PM providing direct sight supervision in the smoking room or in the recreation room, where there are more than 25 residents present.

Resident #1 was observed wheeling himself toward the recreation office, at the far end of the floor, at 4:34:41. He is then seen wheeling back towards the smoking room at 4:36:01 only to return back towards the office at 4:37:04. He is then observed wheeling back in the direction of the smoking room at 4:39:16. There is no staff member with him, behind him, or anywhere around him. He enters the smoking room and pulls out matches from his pants at 4:39:31 and lights a cigarette. He places the used match on the side of his wheelchair seat on what appears to be a white sheet and positions himself against the wall of the smoking room at 4:40:39. There is only partial view of the resident on the video surveillance at this point. Only the lower portions of his legs and wheelchair are visible.

Review of cameras #2, 4, 5, and 6 reveal that there is no staff monitoring the residents in the recreation room or in the smoking room at this time. At 4:44:57, Recreation Aide #1 is observed walking from the recreation office to the staff bathroom, which is halfway between the recreation office and the smoking room. Resident #1 has now been in the unsupervised smoking room for a total of five (5) minutes.

At 4:45:01 the first visual of Resident #1 on fire is noted on the video. It is uncertain as to when the fire actually started as he has been smoking for five (5) minutes, without supervision, and there is only partial view of the resident on the recording up to this point. At 4:45:27 Resident #11, seated at a table outside the smoking room, is seen pointing towards the smoking room. Resident #10 reacts in the same manner, while Resident #14 is seen wheeling himself towards the smoking room. Recreation Aide #1 is observed coming out of the bathroom at 4:45:48 and runs towards the smoking room. Recreation Aide #2 is observed running from the recreation office towards the smoking room at 4:46:02.

Recreation Aide #1, on duty on 4/9/11 during the 12:30PM to 8:30 PM shift, was interviewed on 4/11/11 at 7:30 PM. She stated that she had just finished giving cigarettes to other residents and Resident #1 came to her and said that he needed a match. She went back to the office to get matches from her co-worker and when she returned, the resident was already on fire. The surveyor informed the Recreation Aide that she was observed on video in the recreation office area and that she was then observed going into the bathroom and, following that, towards the smoking room. She stated that she did not recall anything other than going to get matches and returning to find the resident on fire. She stated that she was assigned to monitor the smoking room that day and that she did not leave the room unattended. She further stated that there was no one in the smoking room and she just went to get matches.

Recreation Aide #2, on duty on 4/9/11 during the 9:00 AM to 5:00 PM shift, was interviewed on 4/12/11 at 12:05 PM. She stated that Resident #1 came up at 4:30 PM and was asking for cigarettes. Recreation Aide #1 gave Resident #1 a cigarette and then came back to the office to get matches. Recreation Aide #2 stated that she responded when she heard residents in the recreation room screaming.

The Medical Director was interviewed on 4/11/11 at 9:30AM and 12:30 PM. He stated that Resident #1 was listed in critical condition with burns to 60 percent of his body, including his legs, groin, trunk and arms. The resident was intubated and had a central line placed. The Medical Director stated that he signed the smoking policy but was not really involved in its development. He stated that the residents require supervision while smoking and that all smokers are considered unsafe. The Medical Director stated that he was not involved in the evaluation of the smoking policy because the new policies were doing well.

Observations were conducted during three (3) separate smoking sessions in the smoking room on the 6th floor.

On 4/10/11 between 4:05PM and 4:30PM there was one (1) recreation aide observed with 4 boxes of cigarettes in a plastic container. There were also various lighters and matches in the plastic container. During the observation this aide, who was assigned to monitor the smoking room, did not enter the smoking room at any time. She was observed outside of the smoking room, talking to other residents in the recreation area. From time to time, the aide would observe the smokers in the smoking room through the window that looked into the smoking room from the recreation area. The aide was not in the line of sight with the residents in the smoking room for the entire duration of the smoking session. At one point there were eight (8) individuals smoking in the room, including Resident #14. He was seated in his wheelchair. He lit his cigarette with a set of matches that he pulled out of his own personal belongings and did not relinquish his matches to the recreation aide when he left the smoking room. The aide did not approach him or ask for his lighting materials. Resident #14 was also observed dropping the ash of his cigarette on the floor and lighting another resident's cigarette from his lit cigarette. Resident #6, who had hand tremors, was observed having his cigarette lit by another resident's cigarette. Resident #7 was observed smoking his cigarette down to the butt. Resident #2 had two cigarettes lit at one time. He was observed smoking his cigarettes down to the butt. Resident #3 was observed smoking her cigarette down to the butt. Her cigarette was lit by another resident. The aide did not intervene or address issues that were observed during the smoking session.

Another observation of the smoking room was conducted on 4/10/11 between 6:00PM and 6:40 PM. A newly-hired staff member (CNA) was assigned to the smoking room on that day. The Director of Maintenance was observed instructing her on how to monitor the smoking room. A total of eight (8) residents were observed entering the smoking room with their own cigarettes. During the smoking session it was noted that the assigned staff member was not in the direct line of sight of the smoking room or directly monitoring the residents who were smoking. She was observed standing 2-3 feet away from the smoking room. Resident #7 announced that he had his own cigarette in his pocket; he was also observed smoking his cigarette down to the butt. The CNA did not intervene or address issues during the smoking session.

A third observation of the smoking room was conducted on 4/11/11 between 9:30AM and 10:00AM. An aide was assigned to monitor the smoking session. She was standing approximately six (6) feet from the door/window to the smoking room. She was observed attending to other residents (non-smokers) who were located in the recreation room. At one point, there were nine (9) residents in the smoking room. A resident was observed bringing in her own lighter and lighting cigarettes for other smokers. A second resident was observed with his own lighter. Residents were observed lighting each others' cigarettes. Resident #6 and Resident #7 were observed sharing the same cigarette. Resident #6 was observed with hand tremors. Resident #7 was noted placing a cigarette butt in his pocket. Resident #14 was noted with his own matches.\i At one point, the aide inquired whether a resident had dropped their cigarette on the floor. Although there was no reply to her inquiry, she did not go in the room to investigate whether or not the cigarette was burning on the floor. She did not intervene or address issues that were observed during the smoking session.

On 4/11/11 at 9:50AM an interview was conducted with the Recreation Aide that monitored the 9:30 AM to 10:00 AM session on 4/11/11. The recreation aide stated that she gives out cigarettes. Her responsibility is to make sure that the residents are safe and do not get into fights or fall. She stated that Resident #3 is considered a hazardous resident because she is unsteady in her gait. She identified another resident as an unsafe smoker, stating that he was unsafe due to risk for falls. The recreation aide could only identify two unsafe smokers. She did not indicate that she observes for any other smoking hazards. She stated that she does not report any smoking behaviors to social work. The Recreation Aide stated that some residents carry their own cigarettes because they are more alert or the family provides the cigarettes. When asked why she did not question residents with their own cigarettes or confiscate the cigarettes, she stated that it was not uncommon for residents to carry their own cigarettes.

Resident #2 is a 66 year old male admitted to the facility on 3/9/11 with diagnoses including Seizures, Chronic Obstructive Pulmonary Disease, Paranoid Schizophrenia, and Glaucoma. The MDS 3.0 with an assessment reference date of 3/16/2011 identified the resident as cognitively intact.

The Admission Nursing Evaluation dated 3/9/11 documented that the resident is a smoker. He had a safe smoking care plan dated 3/10/11 which states that the resident will abide by all smoking rules. Interventions include resident will be assessed on cognitive ability to smoke safely, explain terms of smoking contract to the resident, monitor smoking for 5 days for "new" resident for safe smoking, discuss on-going status with team, and monitor on-going smoking practice per nursing policy. A smoking contract was signed by the resident on 3/10/11.

Nursing notes on 3/10/11 state he is very confused and paranoid. On 3/11/11 and 3/1211 he is noted to be non-compliant with medications. On 3/19/11 it is noted that he refused to listen to nurses and aides and continues to pick up hot cups of coffee. There is no smoking assessment in the medical record and he is not listed on the Smoker's list provided.

Resident #3 is an 80 year old female admitted to the facility on 12/22/08 with diagnoses including Dementia, Schizophrenia, and Chronic Obstructive Pulmonary Disease. The MDS 3.0 with an assessment reference date of 3/4/11 documented that the resident was unable to complete the BIMS and had long term memory impairment.

The Admission Nursing Evaluation dated 1/18/11 (on readmission) documented that the resident is a smoker. She is listed on the smoker list as hazardous. Nurse's notes dated 12/14/10 stated that the resident was noted with cigarettes (3 small unlit used butts and 2 empty match cards). A room search was done. In a nurse's note on 12/16/10 at 3AM, it was reinforced not to smoke on the unit and stated "I smoke anywhere I want to." No cigarette or matches found on her. There is no smoking assessment and smoking care plan in the medical record. She is listed on the smoker list as hazardous.

Resident #6 is a 63 year old male admitted to the facility on 11/19/10 with diagnoses including Schizophrenia and Alzheimer's Disease. The MDS 3.0 with an assessment reference date of 2/17/11 identified that the resident has moderately impaired cognition.

The Admission Nursing Evaluation dated 11/19/10 identified the resident as a smoker. The resident had a safe smoking care plan which was initiated on 11/23/10. Interventions include monitoring smoking for 5 days for "new" resident for safe smoking, and monitor on-going smoking practice per nursing home policy. There are no evaluation notes on the care plan. Social Service note dated 12/7/10 documented that the resident is a smoker and is not safe. ( "and is not safe" is crossed out and initialed by the social worker). A smoking contract was signed by the resident on 11/23/10. There is no smoking assessment. The resident is not listed on the smoker's list. The resident was observed during a smoking session on 4/11/11 at 9:30 AM with tremors.

Additionally, Residents #4, 5, 7, 8, 9 and 14 did not have any smoking assessments in the medical record. Residents #1, 5, 8, and 9 did not have any smoking care plans and Residents #8 and 9 were not listed on the smokers' list supplied.

On 4/10/11 at 6:05 PM an interview was conducted with an LPN on Resident #2's unit. The LPN stated that he is not familiar with smokers on his unit and is not aware of a list of smokers.

On 4/11/11 between 6:45AM and 6:50 AM two CNAs working on Resident #6's unit were interviewed. Neither CNA were able to identify the hazardous smokers on their unit nor were they aware of a facility list of known smokers.

On 4/10/11 at 5:55 PM an interview was conducted with an LPN on Resident #3's unit. The LPN stated that she does not know who the smokers are on that unit. She stated that there is no current list of smokers.

The Social Worker was interviewed on 4/11/11 at 9:50 AM. She stated that she meets with the residents upon admission and asks them if they are smokers. If they reply that they smoke, she reviews the smoking contract with them and initiates a care plan. She stated that if staff report concerns about a resident's smoking habits to her, she will change the care plan to indicate that the resident is an unsafe smoker. She stated that Social Services is not involved with the Hazardous Smoker Assessment and does not know who is responsible for completing it. .

The Director of Nursing (DON) was interviewed on 4/11/11 at 7:55 AM. She stated that the Recreation Department is primarily responsible for the smoking program. She stated that some residents who are alert can go up to smoke at any time and are categorized as safe smokers. A Hazardous Smoker Assessment is completed by Social Services through interview. Nursing is only involved if residents do not follow the facility policy, such as smoking in their room or bathroom. The DON stated that a care plan is initiated by nursing if there are any behaviors noted. She stated that Social Services, in conjunction with the Recreation Department, is responsible for identifying and reporting smoking behaviors to nursing. She stated that cognitive impairment and tremors are examples of behaviors that can make a resident an unsafe smoker. The DON stated that the Recreation Department is responsible for generating the smokers list and updating it after interdisciplinary meetings are held and when there are new admissions.

The Safety Coordinator/ Housekeeper was interviewed on 4/11/11 at 10:05 PM. He stated that he does not generate or update the smoker list. He believes that Director of Nursing generates the list because she heads the Safety Committee Meeting every month. The committee meets every month and consists of all the department heads.

The Director of Recreation was interviewed on 4/11/11 at 11:05 AM. She stated that Recreation Aides are responsible to monitor the smoking room. She is aware that the Aides keep their distance from the smoking room when monitoring because the aides do not want to be exposed to second-hand smoke. She further stated that administration is aware of this. Because of the second-hand smoke issue, aides refuse to light residents' cigarettes. Instead, a match/lighter is handed to an alert resident, who will light cigarettes for other residents. The Director of Recreation stated that she is responsible for generating the smoker list based on who is logged-in as a smoker and upon any new admissions. Only residents who come up to smoke are logged in the book.

415.12(h)(1)(2)

Citation date: May 11, 2011

F490 483.75: FACILITY ADMINISTERED EFFECTIVELY TO OBTAIN HIGHEST PRACTICABLE WELL BEING

Scope: Widespread

Severity: Immediate Jeopardy

Corrected Date: May 11, 2011

A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Citation date: April 12, 2011

Based on observations, interviews, and record review the Administrator failed to ensure that systems were in place to adequately monitor and supervise residents while smoking. The Administrator failed to ensure that appropriate policies and procedures related to resident smoking practices were implemented. This includes providing supervision during smoking sessions and adequately assessing/re-assessing residents for safe smoking behaviors. Specifically, a resident who was a known to be an unsafe smoker sustained burns over 60% of his body after an accident occurred while he was smoking without supervision. The resident was hospitalized and is in critical condition.

This was evidenced in 4 of 14 sampled residents (Resident #1). These deficient practices have the potential of affecting all residents in the facility, whose safety from fire hazards is compromised.

This resulted in serious physical harm to one resident (Resident #1), psychological harm to 3 residents (Residents #10, #12 and #14) and the potential for serious harm to the health and safety of all residents in the facility, that is Immediate Jeopardy.

Complaint ID # NY00099858

The findings are:

The Administrator was interviewed on 4/11/11 at 12:20 PM. He stated that he thought that the smoking program was working well. He was not aware of any problems with the smoking policy until this accident occurred. He then stated that he was aware that the Recreation Aides did not want to stand too close to the smoking room door because of second hand smoke. The Administrator stated that he told the Recreation staff that they could stand further back from the smoking room to avoid the second hand smoke. The Administrator was asked how the 26 residents in the recreation room were protected during the fire accident. He offered no reply.

See F 224 K and F 323 L

415.26

Citation date: April 19, 2011

Based on observations, interviews, and record review the Administrator failed to ensure that systems were in place to adequately monitor and supervise residents while smoking. The Administrator failed to ensure that appropriate policies and procedures related to resident smoking practices were implemented. This includes providing supervision during smoking sessions and adequately assessing/re-assessing residents for safe smoking behaviors. Specifically, a resident who was a known to be an unsafe smoker sustained burns over 60% of his body after an accident occurred while he was smoking without supervision. The resident was hospitalized and is in critical condition.

This was evidenced in 4 of 14 sampled residents (Resident #1). These deficient practices have the potential of affecting all residents in the facility, whose safety from fire hazards is compromised.

This resulted in serious physical harm to one resident (Resident #1), psychological harm to 3 residents (Residents #10, #12 and #14) and the potential for serious harm to the health and safety of all residents in the facility, that is Immediate Jeopardy.

Complaint ID # NY00099858

The findings are:

The Administrator was interviewed on 4/11/11 at 12:20 PM. He stated that he thought that the smoking program was working well. He was not aware of any problems with the smoking policy until this accident occurred. He then stated that he was aware that the Recreation Aides did not want to stand too close to the smoking room door because of second hand smoke. The Administrator stated that he told the Recreation staff that they could stand further back from the smoking room to avoid the second hand smoke. The Administrator was asked how the 26 residents in the recreation room were protected during the fire accident. He offered no reply.

See F 224 K and F 323 L

415.26

Citation date: May 11, 2011

F518 483.75(m)(2): TRAIN EMPLOYEES, EMERGENCY PROCEDURES/DRILLS

Scope: Widespread

Severity: Immediate Jeopardy

Corrected Date: May 19, 2011

The facility must train all employees in emergency procedures when they begin to work in the facility; periodically review the procedures with existing staff; and carry out unannounced staff drills using those procedures.

Citation date: April 12, 2011


Based on observation, staff interviews and record review the facility failed to ensure that all existing staff were satisfactorily trained in fire safety/evacuation procedures. Specifically, staff did not respond appropriately to an actual fire emergency situation in an occupied smoking room as outlined in their facility's policy and procedures. Staff failed to initiate horizontal evacuation and extinguish the fire. As a result, a resident who was a known, unsafe smoker sustained burns over 60% of his body after an accident that occurred while he was smoking unsupervised in the smoking room. The resident was hospitalized and is in critical condition.

This was evidenced in 1 of 14 sampled residents (Resident #1). These deficient practices have the potential of affecting all residents in the facility, whose safety from fire hazards is compromised.

This resulted in serious physical harm to one resident (Resident #1), psychological harm to 3 residents (Residents #10, #12 and #14) and the potential for serious harm to the health and safety of all residents in the facility, that is Immediate Jeopardy and Substandard Quality of Care.

Complaint # NY00099858

The findings are:

Resident #1 is a 56 year old male admitted to the facility on 4/6/06 with diagnoses including Schizo-affective Disorder, Psychosis and Paraplegia. The Minimum Data Set 3.0 with an assessment reference date of 11/17/2010 identified the resident with moderately impaired cognition.

A list of "Residents Who Smoke" was supplied by Recreation Aide #3 on duty on 4/10/11 at 12:15 PM. Resident #1 was listed as an unsafe smoker.

The facility is a six story building and has a full sprinkler system. The sixth floor is for activities and a room is provided for smokers. Double smoke barrier doors were observed adjacent to the Activities office. Smoke detectors were noted throughout the recreational area.

On 4/9/11 at 4:34 PM the facility's video surveillance of a fire accident in smoking room on the sixth floor was reviewed. At 4:45:01 PM the first visual of Resident # 1 on fire was noted. The Recreation Aide who discovered the fire in the smoking room enters the smoking room at 4:45:48, and then exits the room without providing any assistance to the resident. Recreation Aide # 2 also enters the smoke room at 4:46:02 PM and exists without providing any assistance. CNA # 1 also responds to the situation and leaves the smoke room without providing any assistance. LPN # 1 also responds to the smoke room at 4:47:36 and then leaves the unit via the stairway. Meanwhile, Resident #1 had been on fire for over two (2) minutes. At 04:50:54 the fire blanket is taken out of the box and placed on the resident. Twenty-six (26) residents were seen observing the fire from the recreation room, without being horizontally evacuated across the smoke barrier door.

The facility's Fire and Emergency Evacuation Manual revised 01/09, included protocols for responding to fire emergencies including emergency removal of residents, first aid, firefighting and evacuation. Horizontal evacuation includes moving residents into another smoke barrier through a smoke/fire door.

The staff that discovered Resident #1 on fire in the smoke room failed to follow appropriate fire and emergency disaster guidelines as stated in the fire safety evacuation plan. Specifically, a fire blanket and a portable fire extinguisher were available within 25 feet of the smoke room. It was not clear if these were used to extinguish the fire. A pull alarm station was located adjacent to the fire extinguisher.

During the review of the event history report from the facility it was noted that the first manual pull of the pull alarm was activated only at 4:48:09 PM. This was well over 2 minutes after the resident was first noted on fire. At 4:50:34 PM, while the fire and smoke were still present, all residents were still in the recreational area without being horizontally evacuated across the smoke barrier door.

The Director of Housekeeping, who is also a fire brigade chief, was interviewed at 10:30AM on 4/11/11. He could not confirm if the smoke detector in the recreational area was activated and triggered the fire alarm. He also stated that all employees are trained in fire safety and drills are provided every month. Additionally, he also stated that at the time of the incident on 4/09/11, the Maintenance Director was the fire brigade chief and it was he that extinguished the fire with the portable fire extinguisher.

In an interview with Recreation Aide # 2 on 4/11/11 at 12:05 PM, she stated that she could not recall if she was ever trained on fire safety and responding to a fire emergency.

In a telephone interview with Recreation Aide #1 on 4/11/11 at 7:30 PM, she stated that she did not use the fire extinguisher or blanket because she could not get it out. She also stated that she could not recall having participated in fire drills since last year.

See K 50 L and K 66 L

415.26(f)(1-3)

Citation date: April 19, 2011

Based on observation, staff interviews and record review the facility failed to ensure that all existing staff were satisfactorily trained in fire safety/evacuation procedures. Specifically, staff did not respond appropriately to an actual fire emergency situation in an occupied smoking room as outlined in their facility's policy and procedures. Staff failed to initiate horizontal evacuation and extinguish the fire. As a result, a resident who was a known, unsafe smoker sustained burns over 60% of his body after an accident that occurred while he was smoking unsupervised in the smoking room. The resident was hospitalized and is in critical condition.

This was evidenced in 1 of 14 sampled residents (Resident #1). These deficient practices have the potential of affecting all residents in the facility, whose safety from fire hazards is compromised.

This resulted in serious physical harm to one resident (Resident #1), psychological harm to 3 residents (Residents #10, #12 and #14) and the potential for serious harm to the health and safety of all residents in the facility, that is Immediate Jeopardy and Substandard Quality of Care.

Complaint # NY00099858

The findings are:

Resident #1 is a 56 year old male admitted to the facility on 4/6/06 with diagnoses including Schizo-affective Disorder, Psychosis and Paraplegia. The Minimum Data Set 3.0 with an assessment reference date of 11/17/2010 identified the resident with moderately impaired cognition.

A list of "Residents Who Smoke" was supplied by Recreation Aide #3 on duty on 4/10/11 at 12:15 PM. Resident #1 was listed as an unsafe smoker.

The facility is a six story building and has a full sprinkler system. The sixth floor is for activities and a room is provided for smokers. Double smoke barrier doors were observed adjacent to the Activities office. Smoke detectors were noted throughout the recreational area.

On 4/9/11 at 4:34 PM the facility's video surveillance of a fire accident in smoking room on the sixth floor was reviewed. At 4:45:01 PM the first visual of Resident # 1 on fire was noted. The Recreation Aide who discovered the fire in the smoking room enters the smoking room at 4:45:48, and then exits the room without providing any assistance to the resident. Recreation Aide # 2 also enters the smoke room at 4:46:02 PM and exists without providing any assistance. CNA # 1 also responds to the situation and leaves the smoke room without providing any assistance. LPN # 1 also responds to the smoke room at 4:47:36 and then leaves the unit via the stairway. Meanwhile, Resident #1 had been on fire for over two (2) minutes. At 04:50:54 the fire blanket is taken out of the box and placed on the resident. Twenty-six (26) residents were seen observing the fire from the recreation room, without being horizontally evacuated across the smoke barrier door.

The facility's Fire and Emergency Evacuation Manual revised 01/09, included protocols for responding to fire emergencies including emergency removal of residents, first aid, firefighting and evacuation. Horizontal evacuation includes moving residents into another smoke barrier through a smoke/fire door.

The staff that discovered Resident #1 on fire in the smoke room failed to follow appropriate fire and emergency disaster guidelines as stated in the fire safety evacuation plan. Specifically, a fire blanket and a portable fire extinguisher were available within 25 feet of the smoke room. It was not clear if these were used to extinguish the fire. A pull alarm station was located adjacent to the fire extinguisher.

During the review of the event history report from the facility it was noted that the first manual pull of the pull alarm was activated only at 4:48:09 PM. This was well over 2 minutes after the resident was first noted on fire. At 4:50:34 PM, while the fire and smoke were still present, all residents were still in the recreational area without being horizontally evacuated across the smoke barrier door.

The Director of Housekeeping, who is also a fire brigade chief, was interviewed at 10:30AM on 4/11/11. He could not confirm if the smoke detector in the recreational area was activated and triggered the fire alarm. He also stated that all employees are trained in fire safety and drills are provided every month. Additionally, he also stated that at the time of the incident on 4/09/11, the Maintenance Director was the fire brigade chief and it was he that extinguished the fire with the portable fire extinguisher.

In an interview with Recreation Aide # 2 on 4/11/11 at 12:05 PM, she stated that she could not recall if she was ever trained on fire safety and responding to a fire emergency.

In a telephone interview with Recreation Aide #1 on 4/11/11 at 7:30 PM, she stated that she did not use the fire extinguisher or blanket because she could not get it out. She also stated that she could not recall having participated in fire drills since last year.

See K 50 L and K 66 L

415.26(f)(1-3)

Citation date: May 11, 2011


Based on observation and staff interviews the facility failed to ensure that all staff were satisfactorily trained in fire safety/evacuation procedures in that three (3) staff members were unable to provide satisfactory answers to questions fire safety procedures implemented in the facility and staff failed to initiate horizontal evacuation of residents on the 6th floor during an unannounced fire drill. These deficient practices have the potential of affecting all residents in the facility, whose safety from fire hazards is compromised.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Complaint # NY00099858
The findings are:
During an onsite revisit of the facility on May 11, 2011 various staff members were interviewed regarding fire safety policy and procedures. For example, 4 facility staffs on the 3rd floor and 6 on the 4th floor were asked fire safety questions to test their knowledge on fire safety procedures implemented in the facility in the cases of an emergency. 2 of 4 facility staffs on the 3rd floor and 1 of 6 staffs on the 6th floor were unable to provide suitable/appropriate answers to the questions asked. They lacked knowledge of the facility's written fire safety procedures. (See K 50).

Additionally, a fire drill was conducted at 1:37 pm in the recreational area on the sixth floor in which a staff member pulled the fire alarm box located adjacent to the smoking room. Twenty eight (28) staff members responded immediately to the area of activation with blankets and fire extinguishers. However, it was observed that no attempt was made by any of the staff members to evacuate the residents in the recreational area. About fifteen (15) residents were left in the recreational area without being evacuated to a safe area across the smoke barrier.

Furthermore, the facility failed to follow its Policy & Procedure on the 5th floor in that there were no staffs stationed to attend to residents and/or ensure their safety. Also, 10 of 12 resident room doors were left open with residents in them and unattended. This is contrary to the P&P implemented in the facility.
In an interview with the Facility's Management and Consultant on 5/11/11 at 2:50 pm, they stated that staff members are properly trained on all fire safety protocols including the importance of horizontal and vertical evacuation. In the preceding fire drills conducted by the facility all staff members had followed this protocol correctly. However, it was not clear as why the staff failed to initiate a horizontal evacuation on the sixth floor. In an interview with the consultant she also stated the importance of evacuating to the nearest smoke barrier since many residents are present in the recreational area.
See K 50
415.26(f)(1-3)

F224 483.13(c): FACILITY PROHIBITS ABUSE, NEGLECT

Scope: Pattern

Severity: Immediate Jeopardy

Substandard Quality of Care

Corrected Date: May 11, 2011

The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.

Citation date: April 12, 2011


Based on observations, interviews and record review the facility failed to ensure that there were systems in place to prevent residents from being neglected during a fire accident. This resulted in physical and psychological harm. Specifically:
A. Staff failed to respond appropriately to a resident (Resident #1) who became engulfed in flames while smoking, sustaining burns over 60% of his body; and
B. Staff failed to remove residents (#10, 12 and 14) from the area of the accident, exposing them to a clear view of Resident #1 while he was engulfed in flames for approximately four (4) minutes, thereby causing them psychological harm.

This was evidenced in 4 of 14 sampled residents. These deficient practices also have the potential to affect all residents that smoke and an additional 22 residents in the facility that witnessed the accident.

This resulted in serious physical harm to one resident and psychological harm to 3 residents that is Immediate Jeopardy and Substandard Quality of Care.

Complaint ID #NY00099858

The findings are:

A. Resident #1 is a 56 year old male admitted to the facility on 4/6/06 with diagnoses including Schizo-affective Disorder, Psychosis and Paraplegia. The Minimum Data Set 3.0 with an assessment reference date of 11/17/2010 identified the resident as moderately impaired cognition.

A Social Service note dated 7/8/10 documents that the resident "is a smoker although he states that he stopped smoking a year ago. Resident has been seen smoking the leftover cigarette butts."

The facility video surveillance was viewed on 4/10/2011 at 12:30 PM. At 4:45:01 PM on 4/9/11, Resident #1 is noted to be on fire in the smoking room. It is uncertain as to when the fire actually started as he had been smoking unmonitored for 5 minutes and there is only a partial view of the resident on the recording at this point.

Recreation Aide #1 is observed coming out of the bathroom and runs towards the smoking room. At 4:45:48 PM, she enters the room, observes the resident on fire and then exits the room without providing any assistance to the resident. She proceeds to make a call on the phone, which is adjacent to the fire blanket and fire extinguisher. She then exits the floor via a stairway at 4:46:10 PM.

Recreation Aide #2 is observed running from the recreation office towards the smoking room at 4:46:02 PM. She also enters the smoking room and then exits without providing any assistance to the resident, who is still on fire.

At 4:46:32 PM Recreation Aide #1 returns to the unit with CNA #1. No one enters the smoking room even though the fire continues to engulf the resident. The CNA goes to the phone as Recreation Aide #1 is pacing in the corridor. The CNA then exits the unit via the stairway. Recreation Aide #1 goes to the phone again at 4:47:20 PM while Recreation Aide #2 is attempting to retrieve water from a dispenser down the hallway. At this point, the resident has been on fire for over two (2) minutes.

At 4:47:33 PM both Recreation Aides are standing by the phone. LPN#1 arrives on the floor at 4:47:36 PM, looks into the room and then leaves the unit via the stairway. At 4:47:44 PM Recreation Aide #2 is seen on the phone again while Recreation Aide #1 is standing right by the fire blanket and fire extinguisher. LPN #1 arrives back on the unit at 4:48:01 with a blanket/sheet. It is thrown on the resident at 4:48:05 PM but the fire is not put out. At 4:48:09 PM Recreation Aide #1 goes and tries to pull the fire blanket out of the box, but is unable to do so. Exhaust from a fire extinguisher can be viewed on the video at this time although it cannot be determined who came in with an extinguisher.

At 4:50:54 PM the Director of Maintenance is observed taking the fire blanket out of its container, which is mounted on the wall, and placing the blanket on the resident. At that point, the fire appears to be extinguished.

The Medical Director was interviewed on 4/11/11 at 9:30AM. He stated that Resident #1 was listed in critical condition with 60 percent of his body burned. The resident was intubated and had a central line placed.

Recreation Aide #1 was interviewed on 4/11/11 at 7:30 PM. She stated that she went down to the 5th floor and told a CNA she needed help and she came right back to the unit. She was on the phone calling out "Emergency Stat 6th floor." The Recreation Aide stated that she did not use the fire extinguisher or blanket because she could not get it out.

Recreation Aide #2 was interviewed on 4/12/11 at 12:05 PM. She stated that Recreation Aide #1 went to call for help and she kept other residents from going into the smoking room, where Resident #1 was on fire. She stated that her co-worker left the unit to get help because no one was responding. The Recreation Aide did not pull the fire alarm. She went to get the fire extinguisher when other staff members arrived. The Recreation Aide could not recall if she was ever trained on fire safety and how to respond to a fire emergency.

CNA #1 was interviewed on 4/12/11 at 2:05 PM. She stated that Recreation Aide #1 came down to her unit on the 5th floor stating that there was a fire on the 6th floor. She went upstairs, saw the fire and tried to get the fire blanket out but was not able to get it out. She then returned to the 5th floor and told the LPN.

LPN#1 was interviewed on 4/11/11 at 6:25 PM. She stated that CNA #1 informed her that there was a fire on the 6th floor. LPN #1 did not hear a fire alarm but she ran up the stairs to the 6th floor. When she arrived she saw many residents on the unit and gave instructions to other staff members to move the residents. She stated she went inside the smoking room and when she saw Resident #1 on fire, she started to scream because she could not believe what she was seeing. LPN #1 could not recall what she did next or how she got the blanket/sheet that she threw over the resident.

The Maintenance Director was interviewed on 4/12/11 at 1:00 PM. He stated that on 4/9/11 he worked from 8 AM to 4 PM and had already punched-out when he heard the fire alarm. He checked the fire panel and noted that it was on the 6th floor so he ran from the basement to the 6th floor with a fire extinguisher in his hand. When he arrived on the 6th floor, LPN #1 was throwing a sheet on the resident. He immediately started using the fire extinguisher because the resident was still on fire.

CNA #2 was interviewed on 4/12/11 at 3:15 PM. She stated that she responded to the fire alarm from the 2nd floor. Upon arrival on the 6th floor she found LPN #1 over the resident in the smoking room and the fire had been extinguished. She saw all the residents sitting around so she left the unit to get additional assistance in order to move the residents. She did not recall being trained on how to evacuate residents and that "everything happened so fast."

LPN #2 was interviewed on 4/12/11 at 3:50 PM. She stated that she responded to the fire alarm from the 3rd floor. Prior to the fire alarm, she did not hear any overhead announcement of any emergency. When she arrived, LPN #1 was in the smoking room on the floor with the resident, who was in a blanket. She looked around and noted that the residents in the recreation room were by the tables or standing around and looking into the smoking room from a large window that separates the smoking room from the recreation area. Another staff member (she was not sure who) asked her to go back to her unit and get Resident #1's medical record. She went down and returned with the record and noted that the residents in the recreation area were still watching everything that was going on in the smoking room. LPN #2 started moving the residents to the other side of the room and instructed other staff members to do the same.

B. Resident #10 is an 85 year old female admitted to the facility on 1/2/08 with diagnoses including Cerebral Vascular Accident, Dementia, Shortness of Breath, and Gait Abnormality. The MDS 3.0 with an assessment reference date of 1/27/11 identified the resident as moderately impaired cognition.

Resident #12 is a 77 year old female admitted to the facility on 10/30/03 with diagnoses including Psychosis, Diabetes Mellitus, and Hypertension. The MDS 3.0 with an assessment reference date of 2/3/11 identified the resident as moderately impaired cognition.

Resident #14 is a 67 year old male admitted to the facility on 2/22/08 with diagnoses including Diabetes Mellitus, Foot Ulcer, Atrial Fibrillation, and Hypertension. The MDS 3.0 with an assessment reference date of 3/18/11 identified the resident as cognitively intact.

The facility video surveillance was viewed on 4/10/2011 at 12:30 PM. Resident#1 was first noted on fire at 4:45:01 PM. At 4:45:27 PM, Resident #11 is observed pointing towards the smoking room through a large window that separates the smoking room from the recreation area. At 4:45:36 PM, Resident #10 is observed pointing towards the smoking room. Resident #14 is observed wheeling himself to the doorway of the smoking room and looking in at the resident that is actively on fire approximately one foot inside the smoking room.

At 4:45:53 PM Resident #1 falls to the floor with the wheelchair while he is still strapped in the chair. At 4:46:19, while Resident #1 is actively burning on the floor of the smoking room, a resident is observed approaching the door of the smoking room. This resident is then noted walking away from the door and back to the door in an agitated fashion. She can be seen pacing around next to the smoking room in obvious distress. Staff is present, but this resident is not redirected away from the direct scene of the fire until 4:47:27.

Camera views of the main recreation area revealed residents moving around in an agitated fashion and crowding to look through the window in the direction of the fire. By 4:47:55PM, Resident #1 has been on fire for over two minutes. The residents in the recreation room are staring into the smoking room. None of the facility's staff can be seen responding to the recreation area in order to safeguard the 26 residents in the recreation room.

At 4:50:34 staff are noted on the unit standing around. All of the residents are still sitting in the recreation room observing the fire. The fire is put out at 4:51:07. At 4:51:40 staff begin to move the residents to the other side of the fire safety doors. By 4:57:19 there are still three residents left in the recreation room when Resident #1 is removed from the smoking room. All residents are not behind the fire barrier until 4:59:35.

On 4/11/2011 at 6:00PM and at 7:05PM an interview was conducted with Resident #10. Resident #10 stated that she was on the 6th floor when the resident caught fire. She stated that she almost fainted because she was scared. She stated that "everyone was screaming and crying," and then she reiterated that she almost fainted. She said that she felt "awful" and that everyone was screaming and she started to scream. Resident #10 said it went on for quite a while and "everyone was scared." Resident #10 did not eat a good dinner that night because she was afraid. The resident was re-interviewed and reiterated all information from her first interview. She also stated that she did not sleep that night because she was thinking about the incident.

On 4/11/2011 at 6:05PM an interview was conducted with Resident #12. Resident #12 was sitting with her back to the smoking room when the resident caught on fire. She said that she heard the resident in front of her yell out that there was fire. She got up to see and saw Resident #1 on fire in the smoking room with very high flames. She stated that "no one was doing anything" and that Resident #1 was crying out in pain. She said that she went in to the room to see what she could do, but the flames were too high. Resident #12 stated "I don't know why nobody was helping him; there was fire all over the place." She also stated "I don't know why they would not help him" She said she was confused as to why they would let him burn.

On 4/11/2011 at 5:50PM an interview was conducted with Resident #14. Resident #14 stated that he was in the recreation room on the 6th floor when Resident #1 caught fire. He stated that he heard Resident #10 screaming. He went to open the door to the smoking room and saw Resident #1 on fire. Resident #1 was still seated in his wheelchair and he was screaming "help me." Resident #14 stated that he wanted to help, but he said he was unable to because he believed he would have caught fire himself. The resident stated that he felt bad when he saw Resident #1 on fire. The resident said, in his mind, he could still picture Resident #1 burning. He is trying to forget about what he witnessed, but he said he keeps thinking about how it could have been him on fire in the smoking room.

An interview with the Director of Operations on 4/12/2011 at 12:00PM revealed that the staff were concerned about residents' reactions to witnessing the trauma and had arranged for all the residents to be evaluated by a Psychologist.

415.4(b)

Citation date: May 11, 2011

K50 NFPA 101: FIRE DRILLS

Scope: Widespread

Severity: Immediate Jeopardy

Corrected Date: May 19, 2011

Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 PM and 6 AM a coded announcement may be used instead of audible alarms. 19.7.1.2

Citation date: April 12, 2011

Based on staff interviews and record review the facility failed to ensure that all staff were appropriately trained in fire safety and emergency procedures in accordance with 19.7.2. This was evidenced by a resident (Resident #1) sustaining burns over 60 % of his body during a fire accident while smoking. Staff members in the sixth floor recreational area failed to respond appropriately when the resident became engulfed in fire while smoking in the smoking room on 4/09/11.

One resident was physically harmed and 3 residents suffered psychological harm due to the failure of staff to appropriately respond to the fire emergency. Additionally, these practices have the potential to affect all residents that reside in the facility, whose safety from fire hazards is compromised.

This resulted in serious physical harm to one resident and psychological harm to 3 residents that is Immediate Jeopardy.

Complaint # NY00099858

The findings are:

The facility's policy and procedure for Fire emergency and Evacuation revised 1/2009 indicated that:

"Every employee is required to become thoroughly familiar with the policy."
"Evacuation includes ALL persons in the danger area ... If a fire starts in your area:

A larm -Transmit alarm via nearest interior alarm box
R escue - Rescue any person in immediate danger.
C onfine - Confine the fire by closing windows, doors.
E xtinguish - Extinguish the fire by using the fire extinguishers or smother by use of blanket, etc..."

"EVACUATION MUST BE STARTED IMMEDIATELY AND MUST BE CONTINUED UNTIL EVACUEES ARE NO LONGER EXPOSED TO DANGER."

The facility's video surveillance of the 4/9/11 fire incident was reviewed on 4/11/11 at 12:30 PM:
At 4:45:01 PM, Resident #1 was first noted on fire.

At 4:45.48 PM, Recreation Aide #1 was observed running towards the "smoke room".

At about 4:45:57 PM, Recreation Aide #1 was again observed entering the "smoke room" and then exits without rendering help to the resident on fire.

At 4:46:02 PM, Recreation Aide #2 was observed running towards the "smoke room" from the recreation office. She enters the room and then exits. She is then seen in front of a sink on the unit at 4:46:15 PM.

At 4:46:32 PM a Recreation Aide #1 returns to the unit followed by a CNA. They did not enter the "smoke room". At 4:46:43 the CNA went to the phone and Recreation Aide #1 was pacing on the unit.

At about 4:47:36 PM an LPN arrived at the 6th floor, looked into the smoke room and then left via the stairway without rendering any help. She was then observed coming back at 4:48:01 PM with a sheet and covered Resident #1 with it.

At 4:48:14 PM the chemical spray from a portable fire extinguisher is seen. The person using the fire extinguisher could not be seen.

At 4:50:54 PM the Director of Maintenance and another employee removed the fire blanket from the box and threw it on the resident at 4:50:58 PM.

Throughout the time that the resident was on fire, other residents are seen on the video surveillance in the recreation room that adjoins the "smoke room". They were observing the incident through a glass window that separates the two rooms and were not immediately evacuated horizontally to a smoke barrier away from the fire. Staff were first seen removing residents away from the area at 4:51:40 PM, after the fire was extinguished.

There was no evidence that staff immediately activated the fire alarm pull box that was located within 25 feet of the incident or used the portable fire extinguisher that was also located within twenty feet of the smoke room where the incident occurred.

The Event History Report that lists the facility's fire alarm activity, indicated that the fire alarm pull box was first used at approximately 4:48:09 PM. This was about 3 minutes from the start of the fire.

Review of the Fire Drill Reports for the previous year did not indicate that recreational staff involved in the incident had participated in fire drills which also included training on fire safety and emergency preparedness.

The Director of Housekeeping, who is also a fire brigade chief, was interviewed at 10:30AM on 4/11/11. He could not confirm if the smoke detector in the recreational area was activated and triggered the fire alarm. He also stated that all employees are trained in fire safety and drills are provided every month. Additionally, he also stated that at the time of the incident on 4/09/11, the Maintenance Director was the fire brigade chief and that it was he that extinguished the fire with the portable fire extinguisher.

In an interview with the LPN on 4/11/11 at approximately 6:25 PM, she stated that the CNA came to her floor and informed her of the fire on the 6th floor. The LPN then took the stairway to the 6th floor, noticed the resident on fire and put a sheet on him. She then ran to get a fire blanket to cover the resident.

In a telephone interview with Recreation Aide #1 on 04/11/11 at approximately 7:30 PM, she stated that it had been over a year that she was in serviced in fire drills and that she works on weekends. Additionally, she stated that she did not use the portable fire extinguisher and the fire blanket because she could not get them out. Review of fire drill records showed that the last in-service she had was in 2006 when she was hired.

In an interview with Recreation Aide # 2 on 4/11/11 at approximately 12:05 PM, she stated that she could not recall if she was ever trained on fire safety and responding to a fire emergency.

711.2 (a) (1)
19.7.1.2 (LSC 2000), 19.7.2

Citation date: April 19, 2011


Based on staff interviews and record review the facility failed to ensure that all staff were appropriately trained in fire safety and emergency procedures in accordance with 19.7.2. Staff members in the sixth floor recreational area failed to initiate a horizontal evacuation during a surprise fire drill. Approximately fifteen residents were left in the recreational area without being evacuated.
Additionally, these practices have the potential to affect all residents that reside in the facility, whose safety from fire hazards is compromised.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Complaint # NY00099858
The findings are:
During an onsite revisit of the facility on May 11, 2011 various staff members were interviewed regarding fire safety policy and procedures. Four facility staffs on the 3rd floor comprising 1 LPN, 1 porter, and 2 CNAs and 6 on the 4th floor, comprising 1 RN supervisor, 1 LPN, 3 CNAs and 1 porter, were asked fire safety procedure questions to be taken in case of fire/smoke emergency in the facility. 2 of the 4 staff members on the 3rd floor and 1 of 6 on the 6th floor were unable to provide suitable/appropriate answers to questions asked. They lacked sufficient knowledge of the facility's written fire safety procedures. Subsequent review of the fire in-service training that was conducted since the fire incidence that burnt a resident 60% of his body showed that the staff members interviewed had been in-serviced.
Additionally, a fire drill was conducted at approximately 1:37 pm on the 6th floor with a simulated " fire situation " in the recreational room where about 15 residents were located at the time. A fire alarm box near the smoking room was pulled to initiate the fire alarm system. Twenty eight (28) staff members responded immediately to the area of activation with blankets and fire extinguishers. However it was observed that there was no attempt made by any of the staff members to evacuate the residents from the recreational room where the " simulated fire " originated as indicated in the facility's fire emergency evacuation Policy & Procedure which states that on the fire floor " Remove any person from the room wherein is a fire and close the door to that room " .
Furthermore the entire 5th floor staff responded to the fire alarm on the 6th floor and none stayed behind to attend to the needs of the residents on the floor. Also, 10 of 12 resident room doors on the floor were left open with residents in them and unattended. The staff thereby failed to follow the facility's Policy & Procedure which states that in the event of fire " Personnel remaining on a floor below a fire shall keep the floor as normal as possible .... " In addition, the P&P states that if a fire starts elsewhere, " unassigned personnel must stay in their normal working areas, out of corridors and follow instructions. All fire doors must be shut and Nurses must reassure residents and close windows and doors " .
In an interview during the exit conference with the Facility's management staff and the consultant on 5/11/11 at approximately 2:50 pm, they stated that staff members were in serviced on all fire safety protocols including the importance of providing horizontal evacuation of residents in danger and that in the preceding drills conducted their staff had followed this protocol correctly, but it was not clear why the staff failed to initiate a horizontal evacuation on the sixth floor.
711.2 (a) (1)
19.7.1.2 (LSC 2000), 19.7.2

K66 NFPA 101: SMOKING REGULATIONS

Scope: Widespread

Severity: Immediate Jeopardy

Corrected Date: April 19, 2011

Smoking regulations are adopted and include no less than the following provisions: (1) Smoking is prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area is posted with signs that read NO SMOKING or with the international symbol for no smoking. (2) Smoking by patients classified as not responsible is prohibited, except when under direct supervision. (3) Ashtrays of noncombustible material and safe design are provided in all areas where smoking is permitted. (4) Metal containers with self-closing cover devices into which ashtrays can be emptied are readily available to all areas where smoking is permitted. 19.7.4

Citation date: April 12, 2011


Based on observations, staff interviews and record review, the facility failed to provide adequate supervision for a resident identified as an unsafe smoker. The facility also failed to implement its own policy and procedures regarding resident smoking in the facility. As a result a "hazardous smoker" (Resident #1) sustained burns over 60% of his body while smoking unsupervised.

One resident was physically harmed and 3 residents suffered psychological harm due to the failure of staff to provide adequate supervision during smoking. Additionally, these practices have the potential to affect all residents that reside in the facility, whose safety from fire hazards is compromised.

This resulted in serious physical harm to one resident and psychological harm to 3 residents that is Immediate Jeopardy.

This resulted in Immediate Jeopardy to resident health and safety.

Complaint # NY00099858

The findings are:

The facility's smoking policy and procedure dated 5/2010 documented that "residents cannot under any circumstances have their own matches, lighters or any smoking material in their possession", and that "smoking shall not be permitted in the smoking room without the direct supervision of a responsible staff member ... throughout the entire smoking period".

Resident #1 is a 56 year old male admitted to the facility on 4/6/06 with diagnoses including Schizo-affective Disorder, Psychosis and Paraplegia. The Minimum Data Set 3.0 with an assessment reference date of 11/17/2010 identified the resident with moderately impaired cognition.

A list of "Residents Who Smoke" was supplied by Recreation Aide #3 on duty on 4/10/11 at 12:15 PM. Resident #1 was listed as an unsafe smoker.

On 4/11/11 during an investigation of a smoking/fire incident reported by the facility's Director of Nursing, it was observed that the facility is a fully sprinklered six story building with a recreation room and adjoining smoke room on the sixth floor. The smoke room can be manually locked from the inside and is accessed with a key from the outside when locked. The smoke room has a glass window that allows supervision of smoking by staff when present in the recreation room.

The facility's video surveillance of the 4/9/11 fire incident was reviewed on 4/11/11 at 12:30 PM:

At 4:38:05 PM, on 4/09/11, Recreation Aide #1 came to the middle of the recreation room, then turned around and went to the far end of the room by the office.

At 4:39:16 PM, Resident # 1 was observed wheeling towards the "smoke room" and was not accompanied by any staff.

At 4:39:31 PM, Resident #1 was observed entering the "smoke room" without any staff present. At 4:39.43 PM, Resident #1 was observed pulling out matches from his pant pocket and lighting a cigarette without staff assistance.

At 4:39:49 PM, Resident #1 was observed placing the used match on one side of his wheelchair seat on what appeared to be a white sheet that was used to cover the wheelchair seat.

At 4:45:01 PM was the first visual of Resident #1 on fire. Prior to this no staff were seen providing direct supervision to Resident #1 who was identified as a hazardous smoker.

During this incident, there were 26 residents in the recreation room and no staff were seen evacuating the residents from the area during the entire time that the resident was on fire.

On 4/11/11 between 9:30AM and 10:00AM, Recreation Aide (#3) was assigned to monitor the smoking session. She was standing approximately 6 feet from the door/window to the smoke room. She was observed attending to other residents that were located in the recreation room. At one point, there were 9 residents in the smoking room. A resident was observed bringing in her own lighter and lighting other resident's cigarettes. A second resident was observed with his own lighter. Residents were also lighting off of each others' cigarettes. Resident #6 and Resident #7 were observed sharing 1 cigarette. Resident #6 was observed with hand tremors\i and Resident #7 was noted placing a butt in his pocket while Resident #14 was noted with his own matches.\i At one point, the aide inquired whether a resident had dropped their cigarette on the floor. Although there was no reply to her inquiry, she did not go in the room to investigate whether or not the cigarette was burning on the floor. She did not intervene or address issues that were observed during the smoking session.

In an interview on 4/11/11 at approximately 9:50 AM with Recreation Aide #3, who was supervising the 9:30 -10:00 AM smoking session, she stated that she gave out the cigarettes and that her responsibility was to ensure that the residents were safe and did not get into any fights or falls. She did not indicate that she observes for any other smoking hazards. She stated that it was not uncommon for residents to carry their own cigarettes.

In an interview with the Housekeeping Director who is also the fire brigade chief for the facility, on 4/11/11 at approximately 10:30 AM, he stated that the recreational aides were assigned to supervise the residents while smoking. There are no other staff members designated to supervise smoking.

The Administrator was interviewed on 4/11/11 at 12:20 PM. He stated that he thought that the smoking program was working well. He was not aware of any problems with the smoking policy until this accident occurred. He then stated that he was aware that the Recreation Aides did not want to stand too close to the smoking room door because of second hand smoke. The Administrator stated that he told the Recreation staff that they could stand further back from the smoking room to avoid the second hand smoke.

711.2(a)(1)
19.7.4 LSC (2000)