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State finds Helena nursing home neglected unsupervised resident who caught on fire

Independent Record - 7/2/2018

June 28--Montana's health department 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.

On behalf of the Centers for Medicare and Medicaid Services, the Montana Department of Public Health and 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 resident who witnessed the incident. The resident died several weeks later.

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.

Because Big Sky Healthcare receives reimbursements from the Centers for Medicare and Medicaid Services (CMS), surveys are completed and reported to CMS when one or more residents suffers "significant harm." The 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.

According to the state health department, 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.

Seth Berg, the administrator in training at Big Sky Healthcare, declined to go into detail about the incident but provided a statement.

"Big Sky Healthcare Community strives to provide the highest quality of care to our residents," the statement said.

The statement acknowledged the incident, but said safety standards are still high at the facility.

"In contrast, the most recent survey conducted by an outside, independent agency found that satisfaction in safety and security at Big Sky Healthcare Community ranked higher than the national benchmark average."

"Big Sky Healthcare Community promptly and directly addressed the state citation through our Quality Assurance and Performance Improvement process, which includes, but is not limited to, immediate resolution of the concern, evaluation of the root cause of the concern and ongoing monitoring to assure the issue is resolved. This established process was implemented in the case of this citation," the statement said. "Big Sky Healthcare Community, however, does not agree with the findings and is contesting the citation through the State's required process."

A spokesperson for the state health department said the state will revisit Big Sky healthcare unannounced to ensure compliance with the plan submitted by the facility.

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. The report doesn't include the resident's cause of death.

On May 1, the resident was let outside by a therapist and left unsupervised with another resident who was smoking. When staff responded to the resident on fire, she was yelling "he told me it was off, why would he tell me it was off." Because the report keeps all staff and residents anonymous, it's unclear who she was referring to. The woman later reported to the emergency room physician that she was not smoking, but took a drag of another resident's cigarette and her oxygen ignited. She had second degree burns on her face and left hand.

The resident who witnessed the incident and said it took 10 minutes for staff to get to the woman on fire, said "sometimes there wasn't any staff out there when the residents were smoking."

Interviews with staff members about the facility's smoking policy contradicted each other regarding when residents were allowed to smoke, if they were allowed to possess their own cigarettes or if there were safety measures -- like smoking aprons to keep people in wheelchairs from getting burned -- available for residents to use.

Previous incidents with the resident indicate she was caught smoking three times but was still allowed to smoke. One 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 contradicted that policy and said residents were allowed to keep cigarettes and lighters in their rooms.

While the report noted only one incident of a resident getting injured due to neglect by staff, the survey found that a total of four residents were put in danger because the staff did not provide adequate supervision while smoking to prevent accidents.

One resident said he "used to be able to keep his cigarettes and lighter and everything until resident #1 blew herself up," but now the staff keeps everything.

In addition to neglecting patients, the report found the facility failed to adhere to a requirement to report the incident to adult protective services and the state health department. The report says "the facility failed to report and investigate the event with a resident smoking with oxygen, without supervision, who received second degree burns. ... This had the potential to affect other residents who smoked that were on oxygen."

Observation from the state also found residents could access medication without supervision.

One patient had several medications in her room at all times, although records showed there was no assessment of whether a patient could administer her own medications nor a doctor's order to do so.

Another resident who uses inhalers said staff leave some of his medications in the room "sometimes." He also said he keeps inhalers stored away in a drawer "just in case they don't get to me in time."

The plan submitted by Big Sky Healthcare addresses all of the concerns in the state's survey.

Big Sky Healthcare became a nonsmoking facility on May 23, although residents who were smoking prior to that date will be allowed to smoke with supervision at designated times. All cigarettes and lighters will be kept by staff, and residents on oxygen will not be allowed in the smoking area. All staff is educated on the updated smoking policy, according to the plan. An administrator will conduct random checks three times per week for a month to make sure residents aren't smoking without supervision.

If the staff suspects residents are smoking in non-designated areas, daily room searches will be conducted and a smoking assessment will be completed. A fire extinguisher and fire blanket are now in the smoking area in case of emergencies.

An administrator will also be responsible for reporting all incidents of abuse or neglect to the state health department and educate all staff on the policy. The administrator will also conduct audits to make sure all incidents have been investigated and reported.

Medications were removed from rooms until a self-administration assessment was completed, and administrators will check to make sure residents are safely storing allowed medications.

The state health department checks on all nursing homes every 15.9 months at a minimum, according to a spokesperson. The state will also check on facilities when a complaint indicates that residents are at risk. Each complaint is triaged based on severity of the allegations, the spokesperson said.


(c)2018 Independent Record (Helena, Mont.)

Visit the Independent Record (Helena, Mont.) at www.helenair.com

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