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RISKAlert Report Updated:  July 5, 2018                                                                                           Helena, Montana

NURSING HOME MAY LOSE CMS MEDICARE FUNDING AFTER RESIDENT  IGNITED OXYGEN TANK WHILE
SMOKING, CAUGHT  FIRE AND BURNED FOR TEN MINUTES

Montana’s Health Department recently found that a Helena nursing home was neglecting patients, after an unsupervised resident smoking a cigarette on oxygen caught on fire and suffered second-degree burns in May.  The resident died several weeks later.  The facility had a new non-smoking policy in place.

As part of a CMS Survey, the Montana Department of Public Health &Human Services conducted a survey of Big Sky Healthcare Community after receiving a complaint about the facility. The survey found that the Helena facility neglected the resident when she was outside unsupervised on May 1.

The resident was on fire for approximately 10 minutes before staff reached her and called emergency medical services, according to a witness.  The survey also found the facility failed to report the incident, various staff members were unclear on the facility’s smoking policies and some residents were inappropriately left to administer their own medications.

The CMS Survey classified the incident as an “immediate jeopardy” situation, meaning the facility had to take immediate corrective actions to protect residents or risk losing its Medicare and Medicaid certification.  Big
Sky Healthcare successfully removed the immediate risk while the state workers were on site. The facility later had to submit a detailed corrective action plan to address all of the issues identified by the state.

The resident, who is not named in the report, was caught smoking multiple times by staff in the months prior to catching on fire. The resident came to the facility in December 2017 with a lung disease that restricts breathing and required supplemental oxygen.  The resident was burned on May 1, admitted to hospice on May 8 and died on May 24, according to the report.

A staff member said the facility’s policy required nurses to keep cigarettes and lighters stored away from patients, but nurses don’t enforce that. The staff member said management was aware nurses were not enforcing the policy. Another staff member said residents were allowed to keep cigarettes and lighters in their rooms.

LESSONS LEARNED:

1. Nursing home residents should never be allowed to smoke. Policies should be adjusted to
   reflect this, and staff should be trained on how to report infractions.
2. If residents are unfortunately allowed to smoke, They should be under constant supervision and
   oxygen tanks should be far away from the resident.

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