BIRMINGHAM, AL- BIRMINGHAM NURSING AND REHABILITATION

Based on interviews, review of a policy titled Quality Improvement Program, review of the facility’s QAPI (Quality Assurance Process Improvement) Plan and review of the facility’s 03/26/2022 MONTHLY FACILITY QA & A (Quality Assessment and Assurance) MINUTES, the facility’s Quality Assurance (QA) committee failed to thoroughly review all factors related to Resident Identifier (RI) #177’s fire and injuries, to determine what corrective actions needed to be taken to prevent any further resident safety concerns.

On 03/26/2022, RI #177, a resident with a documented history of smoking noncompliance, was in
possession of his/her smoking materials and lighter, and subsequently ignited his/her bedding and body. After staff became aware, they extinguished the flames, rendered necessary aid, and RI #177 was sent to the hospital where he/she was found to have 3rd degree burns covering 10-19% of his/her body.

This failure placed all remaining residents in the facility at risk for immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. The facility Form CMS-672 listed a facility census of 129 at the time of the survey.

The facility’s investigative summary related to this incident documented RI #177’s roommate exited their room and yelled for a nurse, alerting staff there was a fire. EI #23, a Licensed Practical Nurse (LPN), ran to the room and found RI #177 in bed with his/her torso, groin and arms ablaze. After staff extinguished the resident and attended to his/her immediate needs, including cutting off smoldering clothing, RI #177 was transferred to a local hospital for evaluation and treatment. The facility’s summary documented, Facility and fire department is in agreement that resident had smoked in bed and cigarette fell into bed causing linens and clothing to catch fire.

EI #1, the Administrator, was interviewed on 04/13/2022 at 9:25 AM. EI #1 was asked if she has any concerns with resident SMOKING SAFETY EVALUATIONS not being complete or accurate. EI #1 stated the facility’s evaluation forms are confusing, and acknowledged it was hard to tell at what point the forms were correct with multiple dates and signatures. EI #1 said the smoking evaluations were not meant to be a multi-use form, as it was being utilized by staff. EI #1 initially said the facility recognized the problem with the evaluation forms on 03/26/2022, but when questioned why the same forms had been being utilized since then, EI #1 said they originally intended to make it a single use form, but then later decided to do away with the evaluation tool they were utilizing. EI #1 indicated that decision had been made on 04/06/2022 but the facility’s efforts to address it were not complete. EI #1 was then asked about concern with care plans being
based on incomplete and inaccurate smoking evaluations. EI #1 said this resulted in a care plan that was not detailed enough for staff to know what to do or what to report. EI #1 said staff usually reported concerns to her during their morning meetings, and acknowledged she had been informed of three different smoking related incidents prior to the fire on 03/26/2022. EI #1 said she did not know why staff were not informing her of the smoking incidents. EI #1 further stated inconsistency with enforcing policy and reporting inconsistency resulted in inconsistent actions taken with each smoking incident. EI #1 said if staff did not report the concerns to her, she could not ensure appropriate actions were taken. When asked what had been done as a result of the 03/26/2022 fire, EI #1 said they had a QAPI meeting on 03/26/2022 and the facility’s smoking policy was updated to reflect no residents should have possession of lighters or flame producing items. EI #1 said she did not know why there seemed to be a communication breakdown related to smoking incidents, because staff communicated with her regarding other things.