The resident told staff after the incident: "I just wanted to smoke a cigarette." When he lit his lighter, "the lighter blew up on his face," according to nursing notes from Franciscan Post-Acute Care Center. The charge nurse found blood on his mouth and nose, soot covering his face, and his beard burned off and still smoking.
Emergency responders transported the resident to an acute care hospital's burn unit, where he remained for two days. Hospital records documented "partial thickness burns to the left cheek," "superficial burns to the left eyelid," burns to his lip, and soot in his nose. His left eye was swollen shut.
Staff had known for months that the cognitively intact resident was bringing cigarettes and lighters into the smoke-free facility after his regular hemodialysis appointments. A nursing note from October 31st documented finding "8 Norco's in his bag, a pocketknife, and a lighter" when he returned from dialysis. The nurse told him he couldn't keep the lighter at his bedside, but allowed him to take it when leaving for future dialysis appointments.
"Resident stated that he needs his lighter for when he goes to dialysis," the note read. "Informed resident that he can take the lighter while he goes out for dialysis, but he needs to give it back to the nurse to put in the narcotic box after he comes back."
The facility's Director of Nursing told inspectors she was aware staff gave the resident his cigarettes when he left for dialysis while wearing oxygen. She said he would "smell like smoke when he returned from dialysis." On January 10th, the transportation company threatened to stop providing his rides after he tried to smoke in their van.
A paid caregiver for the resident's roommate witnessed him smoking inside the facility over a weekend. She saw him wheel his chair to the sliding glass door with a cigarette and asked what he was doing. "He replied he was going to smoke," she told inspectors. "I told him you are not going to smoke that in here."
The facility had caught the resident smoking in his room while on oxygen as early as November 10th. An interdisciplinary team note from the following day stated they "spoke with him again today and reminded him that there is no smoking allowed in this facility." They offered to refer him to another facility or get a nicotine patch order. "He declined both options."
His daughter had previously told the Director of Nursing that the resident "had accident in the past while smoking with oxygen on" and "would not stop because he was stubborn."
The resident's care plans contained contradictory and ineffective interventions. One plan from November included providing him with "a cigarette holder while smoking" and "a smoking apron while smoking," despite the facility being smoke-free. The Director of Nursing admitted she "did not know why the interventions included the smoking apron and cigarette holder because the resident was not supposed to smoke onsite."
Another care plan from December noted his "non compliant behavior" during dialysis days but relied on education as the primary intervention. The Director of Nursing acknowledged the resident "was known to be non-compliant and the intervention of providing education was not effective."
When the resident was admitted, the Admissions Coordinator reviewed the smoking policy with him. "The resident became upset, crumpled up the policy and procedures and threw it on the bed," she told inspectors.
The night of the fire, a nursing assistant had searched the resident's belongings when he returned from dialysis on February 3rd and found no cigarettes or lighter, "which was unusual because he normally had them when he returned." Staff discovered additional cigarettes in his room after the incident.
The maintenance supervisor found burn holes in the resident's mattress and had to replace charred floor tiles. The mattress had five holes, with the largest showing melted foam. Only the fire-retardant material prevented the mattress from continuing to burn.
Hospital records showed the resident complained of nasal dryness with scab formation making it difficult to breathe through his nose when he was discharged back to the nursing home two days later. He reported continued facial pain.
The Administrator told inspectors: "We cannot control what he does when he is out of the facility. He is going to do what he is going to do."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Franciscan Post-acute Care Center from 2025-02-05 including all violations, facility responses, and corrective action plans.
Additional Resources
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