Nursing Homes Abuse Blog - By Jonathan Rosenfeld

Authorities are now investigating the smoking-related death of a 62-year-old man at a Chicago nursing home.  The man identified as, Lawrence Lewis, suffered first and second degree burns to more than 20% of his body after his clothes caught fire while lighting a cigarette in an outdoor smoking area.

After struggling with another patient to extinguish the fire, a third person at the nursing home used a fire extinguisher to put out any remaining flames. 

The Chicago Fire Department transferred Mr. Lewis to nearby Saint Frances Hospital in Evanston.  Due to the severity of his burns, Mr. Lewis was eventually transferred to Loyola University Medical Center where he eventually died.

Special considerations for disabled nursing home patients who smoke

According to news reports of the incident, Ms. Lewis was a wheelchair-bound patient at the facility.  Though I have no information about Mr. Lewis's physical abilities, nursing homes in general need to take special precautions when they care for physically (and mentally) impaired patients who smoke.

Obviously, the biggest threat smoking poses to a disabled person is their inability to move out of the way if an ember or match falls on them. Understanding this obvious problem, nursing homes have a duty to implement precautions for these vulnerable patients.  While some precautions, such as smoking vests (a flame retardant fabric placed over patients laps), make good sense--- the most important prevention a nursing home can implement is to provide adequate supervision while patients are smoking.

Again, while I have no specific information about this incident, the lawyer in me wonders exactly where the staff were at the time this incident occurred.  Having represented nursing home patients and families in nursing home smoking cases, I find staff no where to be found when a patient needs their assistance.  While we learn more about the specifics of this case, my thoughts and prayers are with this man's family.

Related:

When Safety Is An Afterthought, Smoking Is One Of The Most Dangerous Nursing Home Activities

Man Fatally Lights Self on Fire in Smoking Accident at Nursing Home, My Fox Chicago, August 3, 2011

Smoking-Related Fires Are A Real Threat To Nursing Home Patients. Is It Time To Put Out The Fire?

Man in wheelchair dies in fire caused by smoking By Liam Ford, Chicago Tribune, August 2, 2011

Smoking remains one of the most ordinary--- yet perhaps the most dangerous activities that takes place in nursing homes everyday. 

Maybe its due to the fact that smoking is such a commonplace activity in nursing homes, many staff simply fail to understand its potentially dangerous impact on both the individual smoker--- as well as the overall safety of all patients and staff at the facility.

The fact remains, hundreds of thousands of nursing home patients smoke cigarettes on a regular basis.  As such, nursing homes need to both create and implement a smoking safety policy to minimize the chance of fire and injury at their facilities.  Further, the smoking policy should be reviewed with patients and their families to help encourage compliance and rectify and misunderstandings.

Though certainly not formally addressed by federal or state law, many nursing homes have incorporated some of the following safety protocols in their smoking policies:

• Limit smoking activities to particular areas-- indoors or out
• Never allowing smoking in bed or individual patient rooms
• Keep smoking materials away from oxygen tanks and other flammables
• Provide 'smoking aprons'- fire retardant devices to prevent clothes from catching fire
• Provide adequate staffing so patients who require assistance can be adequately supervised

Disastrous Consequences Related To Inadequate Safety

I was reminded of the life-changing injuries that can rapidly result when smoking policies are not properly implemented when I read about an Australian woman in a nursing home who sustained severe burns to more than half of her body when the cigarette she was smoking dropped and lit her clothes on fire.   Shortly after the incident, the woman died from the resulting burns.

An inquiry into this nursing home incident revealed that the incident occurred when the woman was left to smoke-- without any staff supervision-- as the care plan created by the nursing home suggested.  Like many nursing home patients, this woman suffered from conditions such as: dementia, arthritis, and a history of dropping her cigarette ashes onto her lap.

As a nursing home lawyer, who has litigated smoking-related injury cases, I share the frustration and anger many families experience when their loved one is injured while smoking at a nursing home.  Certainly, facilities need to recognize the smoking-dangers and assign the necessary staff to maximize patient safety.

Related Nursing Homes Abuse Blog Entries:

Burns In The Nursing Home Population Pose A Serious Threat Of Injury & Further Medical Complications

Smoking-Related Fires Are A Real Threat To Nursing Home Patients. Is It Time To Put Out The Fire?

Nursing Home Patient Suffers "Life threatening Injuries" In Smoking Incident

A hot cup of soup, a radiator, an uncalibrated water thermostat or a fire can all pose serious burn risks for nursing home patients. Your skin is necessary for your body’s regulation of fluid and temperature; it also acts as a barrier against bacteria and viruses. When you burn your skin, you put yourself at risk for infection, tetanus, scarring, permanent injury, and even death depending on the severity of the burn. 

Stages of Burns

Burns are categorized as first degree, second degree, or third degree based upon the depth of the burn and the percentage of total body area affected. 

First-Degree Burn

A first-degree burn is the least serious type of burn where only the outer layer of skin (dermis) is burned. Symptoms include: redness, mild swelling, and skin that is tender to the touch.  

Second-Degree Burn

A second-degree burn occurs when the first and second layer of the skin is burned. Symptoms include: blisters, reddened and splotchy skin, swelling, and pain.  

Third-Degree Burn

A third-degree burn is the most serious type of burn and occurs when all layers of the skin are burned. This causes permanent tissue damage and may affect fat, muscle, and even bone. Third-degree burns damage the nerves and blood vessels, which can lead to a white and leathery appearance of the skin. Symptoms include: severe pain, areas of charred black skin, or skin may appear white or dry.  

If you suffer a burn (second or third-degree) that covers more than 15-20% of your body, you are at risk for significant fluid loss, which could lead to shock if fluids are not replaced intravenously. If you suffer a burn affecting over 50% of your body, then you have a significant mortality risk, especially if compounded by underlying medical conditions and advanced age. 

Burn Treatment

In order to properly treat a burn, it is important to first determine the extent of tissue damage. Minor first-degree burns and second-degree burns that are no larger than 3 inches in diameter require different treatment than third-degree burns. It is important that burns are properly and thoroughly cleaned in order to prevent infection because your body’s barrier against germs. 

For minor burns, you should:

• Cool the burn (hold burn under cool running water or immerse in cool water for 10-15 minutes)
• Cover the burn with a sterile gauze bandage (wrap gauze loosely)
• Take an over-the-counter pain reliever (aspirin, ibuprofen, naproxen, or acetaminophen)

It is important that you do not use ice directly on the burn (which could cause further damage to the wound), do not apply ointments to the burn (which could cause infection), and do not break blisters (which makes them more vulnerable to infection). As the burn heals, watch for signs of infection, symptoms include: increased pain, fever, redness, swelling, or oozing. 

For major burns, which are third-degree burns or large second-degree burns, you should contact emergency medical help and follow the following steps:

• Do not remove burned clothing
• Do not immerse burns in cold water (which could cause hypothermia and shock)
• Check for signs of circulation (breathing, coughing, or movement)
• Elevate the burned body part or parts
• Cover the area of the burn

Also, for severe burns, it is important to get a tetanus shot or make sure you have had one in the last ten years because burns are susceptible to tetanus. 

For major burns, doctors can use skin grafts to improve the function and appearance for large burn areas. A skin graft is a surgical procedure where a piece of skin from the donor area of the patient’s body (usually the buttocks or upper thighs) is transplanted to the damaged area of the patient’s body. The graft can help reduce fluid loss, protect the burn from infection, reduce pain, allow tissues underneath to heal, and improve the appearance of burned skin. In order to prepare the burned area for the skin graft, doctors remove (excise or debride) the burned skin. There are also skin banks, which store donor skin from organ donors, which provide donor skin that can be used for temporary skin grafts. 

Preventing Burns in Nursing Homes

Older adults (≥ 60 years) are at increased risk for burn accidents, second only to young children. The National Fire Prevention Agency reported that adults age 75 and older are the age group most likely to die in house fires. Older adults also suffer larger size burns on average than any other age group. The most common type of burn injury for older adults is usually a scald (a type of burn injury caused by hot liquids or steam). Also, elderly burn victims have a higher mortality rate than younger burn victims. 

As you age, so does your skin, and the skin of older adults is dry, wrinkled, loose, and less elastic because the dermis layer of the skin becomes thinner over time. This makes the skin more susceptible to the absorption of heat, which means that even moderate heat sources (warm water, electric blankets, radiators) can cause serious physical damage. Also, older adults are more susceptible to fluid loss and shock after suffering from a burn, which requires proper fluid replenishment. 

Elderly nursing home residents are more susceptible to dangerous burns because of their advanced age, prevalence of mental illness, reduced mobility, and underlying medical conditions. Many elderly nursing home residents are weak and vulnerable because of disease and illness, which makes any additional illness or injury all the more dangerous. 

Therefore, it is important that nursing home staff members take steps to reduce burn risks. This includes monitoring the temperature of the water in resident bathrooms to prevent scalding, monitor the temperature of food served to residents, not allowing candles or other open flames, covering radiators, and complying with proper fire prevention and safety standards. 

If you or a loved one suffer a serious burn while living in a nursing home, you may be entitled to collect damages. Nursing homes must provide safe environments for their residents and monitor residents to ensure that there are not any burn risks and that all injuries are properly treated.   When nursing homes fail to meet this duty, they can be liable for negligence. 

Thank you to Heather Keil, J.D. for her assistance with this important topic.

Resources:

Burn Survivor Resource Center: Medical Care Guide
The Mediterranean Council for Burns and Fire Disasters: Annals of Burns and Fire Disasters: Considerations on Intensive Care in Elderly Burn Patients
Burn Recovery: Skin Grafts for Burn Treatment

Related Nursing Homes Abuse Blog Entries:

Smoking-Related Fires Are A Real Threat To Nursing Home Patients. Is It Time To Put Out The Fire?

Unsupervised Nursing Home Resident Dies From Burns

Even The Most Mundane Parts Of A Nursing Home Can Turn Deadly Without Proper Staff Supervision

Cigarette Lighter Mishap Results In Severe Burns To Nursing Home Patient

It only is a matter of time before another nursing home fire claims the life of another patient.  While less publicized, hundreds of elderly people receive burns every year during their admission to skilled nursing facilities. Anyway you look at the situation, fires in nursing homes remain a real-- yet under-appreciated threat to nursing home patient safety.

According to the Government Accountability Office (GAO), from 1994 to 1999 approximately 2,300 nursing homes reported some type of fire at their facility each year.    Equally alarming is that the GAO has found the number of severe fire deficiencies in nursing home has increased steadily from 2004 through 2007.

In response to this safety threat, Centers for Medicare & Medicaid Services (CMS) now requires a smoke detector in every patient room and in public areas.  Additionally, automatic fire sprinkler systems must not be installed in new facilities and retrofit in existing facilities over the next four years.

While compliance with CMS regulations may help reduce the chance of fires in skilled nursing facilities, owners and administrators should evaluate all activities and determine what policies may be implemented to further promote patient safety.

Step #1: Eliminate Smoking In Nursing Homes

Smoking in nursing homes can at best be considered counter-productive to patient health.  Perhaps more accurately, smoking in nursing homes is threat to all patients and staff. Even when monitored, there is an increased risk of fire in nursing facilities that permit smoking compared with those that do not allow it.  Therefore, I propose nursing homes force patients to toss out their cigarettes or seek alternative facilities.

In addition to safety concerns related to fire, allowing patients to smoke in a nursing home diverts staff resources to the supervision of patients who choose to smoke and away from the task of providing skilled nursing care. 

According to The National Fire Protection Association, elderly people are more than three times more likely to suffer a smoking-related injury than their younger counterparts.  One need not look far to see examples of smoking accidents in nursing home and assisted living facilities:

• Dallas, Texas- Woman dies in a fire at an assisted living facility.  The fire inspector determined the fire started due to 'improper use of smoking material'
• Chicago, Illinois- Two patients died at Hampton Plaza Nursing Home from smoke inhalation. The fire department concluded that the fire was started by smoking materials stored in a patient's closet.
• Whittier, California- A nursing home patient with dementia ignited himself while attempting to light his cigarette.  A investigation into the matter revealed the staff was unaware that the man was even outside of the facility.
• Lebanon, Indiana- An oxygen dependent patient started a fire at an assisted living complex when the oxygen tank exploded as she smoked.  

I doubt we will nursing homes flocking to change their policies to 'smoke free' overnight.  In the meantime, facilities should take steps to develop a smoking policy that is both realistic to implement and enhances patient safety.  Here are some suggestions for developing a smoking policy:

• Designate a smoking area for patients that is supervised and well ventilated.
• Ban all smoking in patient rooms.  Studies have shown that the risk of fire increases when people smoke in bed.
• Establish an evacuation policy in case of a fire or emergency.  Similarly, inform all staff and patients as to the location of fire extinguishers and teach them how to use it.
• Keep all smoking materials including lighters and matches in possession of staff and locked at all times.
• Provide ashtrays and smoking aprons (outerwear made from fire-proof material that reduces the chance of a stray ash igniting a patients clothing) 
• Develop a smoking cessation program.
• Make sure your facility has smoke detectors and a sprinkler system
• Allow patients to smoke only when supervised by staff members.
• Develop a set of consequences for patients who fail to follow the policy.
• Write down your facilities smoking policy and give a copy to all patients and their families.

While the above guidelines may reduce the chance of fires in nursing homes, eliminating smoking remains one of the easiest ways to improve the overall living conditions for all patients and nursing home staff.

Resource:

GAO Report, Fire Safety In Nursing Homes- Recent Fires Highlight Weaknesses in Federal Standards and Oversight, July, 2004

Nursing Home Compare-  See how your facility measures up with respect to fire safety

Related Nursing Homes Abuse Blog Entries

Maximum Fine Levied Against Nursing Home For Failing To Supervise Resident While Smoking

Resident Who Smoked & Used Oxygen Suspected Of Causing Fire At Assisted Living Facility

Unsupervised Nursing Home Resident Dies From Burns

The report of a fire at Jaycee Village Retirement Community, an Ohio Nursing Home, demonstrates the importance of fire safety in all nursing homes.  Although, no residents were injured, the episode demonstrates how a fire in a nursing home could severely harm residents who are unable to move quickly because they are bed-bound or in wheelchairs.

In June, 2008 CMS, the governmental agency regulating Medicare and Medicaid funded nursing homes, gave all nursing homes receiving federal funding five years to phase in the installation of sprinkler systems at their facilities.  According to a report from the Government Accountability Office, fire sprinklers can decrease the chances for fire-related death by 82%. 

Currently, all nursing home must have battery operated smoke alarms in all patient rooms and public areas.  Further, all nursing home receiving public payments are subject to random fire safety inspections.