March 23, 2007
To: All Nursing Home and Adult Care Home Providers
From: Jeff Horton, Chief Operating Officer
Resident Safety Regarding Smoking
There continue to be instances concerning resident smoking in nursing facilities and adult care facilities that result in fires. As a result of these fires, there have been resident deaths, several resident injuries and danger to other residents residing in the facilities. In addition, when fires occur, residents may have to be displaced from the facility they live in and moved to another facility, which can be disruptive and chaotic, especially for confused residents. The purpose of this memorandum is to alert and remind facilities of the need to provide adequate protections for residents who smoke.
Regulatory Requirements
There are a number of regulations in effect for nursing and adult care facilities that address resident safety and supervision, which would include when residents smoke.
For nursing facilities these regulations include:
- Federal Regulations at 42 CFR 483.25(h)(2) [Tag F324]: The facility must ensure that - Each resident receives adequate supervision and assistance devices to prevent accidents; and
- State Licensure Rules at 10A NCAC 13D .2208(e)(2): The facility shall ensure that each patient receives adequate supervision and assistance to prevent accidents.
- State Licensure Rules at 10A NCAC 13D .3101 General rules which adopts the North Carolina State Building Codes by reference: N.C. Fire Prevention Code section 310.1.- 310.8: sets standards and specific requirements for smoking and protection from hazards related to smoking. (See Guidelines)
- Federal Regulations at 42 CFR 483.70(a) [Tag K66]: Smoking regulations shall be adopted and shall include not less than the following provisions: 18.7.4, 19.7.4 (of the 2000 Life Safety Code)
- Smoking by patients classified as not responsible shall be prohibited, except when under direct supervision.
- Ash trays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
- Metal containers with self-closing cover devices into which ashtrays can be emptied are readily available to all areas where smoking is permitted.
- State Sanitation Rules at 15A NCAC 18A .1311 for Hospitals Nursing Homes, Adult Care Homes, and other Institutions
(e) Indoor smoking, including the carrying of any lit cigarette, pipe, cigar, or other similar product containing tobacco or other substances shall be restricted to dedicated smoking rooms. Smoking rooms shall be ventilated to prevent environmental tobacco smoke from moving into other occupied portions of the building. There shall be no obligation to establish such smoking rooms.
For adult care homes these regulations include:
- State Licensure Rules at 10A NCAC 13F .0704(2) and 10A NCAC 13G .0704(2) An adult care home administrator or administrator-in –charge shall furnish and review with the resident and the resident or responsible person information on the home upon admission and when changes are made to that information. A statement indicating that this information has been received upon admission or amendment as required by the Rule shall be signed and dated by each person to whom it is given and retained in the resident’s record in the home. The information shall include the following:
(2) a written policy of all house rules, including facility policies on smoking, alcohol consumption, visitation, refunds and the requirements for discharge of residents consistent with the rules of this Subchapter, and amendments disclosing any changes in the house rules. - State Licensure Rules at 10A NCAC 13F .0901(b) and 10A NCAC 13G .0901(b): Staff shall provide supervision of residents in accordance with each resident’s assessed needs, care plan and current symptoms.
- State Licensure Rules at 10A NCAC 13F .0302 and 10A NCAC 13G .0302 CONSTRUCTION which adopts the North Carolina State Building Codes by reference: NC Fire Prevention Code section 310.1.- 310.8: sets standards and specific requirements for smoking and protection from hazards related to smoking. (See Guidelines)
- State Sanitation Rules at 15A NCAC 18A .1311 for Hospitals Nursing Homes, Adult Care Homes, and other Institutions
(e) Indoor smoking, including the carrying of any lit cigarette, pipe, cigar, or other similar product containing tobacco or other substances shall be restricted to dedicated smoking rooms. Smoking rooms shall be ventilated to prevent environmental tobacco smoke from moving into other occupied portions of the building. There shall be no obligation to establish such smoking rooms.
Additional Considerations
In addition to the above regulations, there are a number of factors facilities should consider regarding residents who desire to smoke. Listed below are some of these factors. Please note the below list is not all-inclusive as each situation is different and may vary according to resident and facility characteristics.
- Facility policy – Perhaps one of the first considerations regarding resident smoking should be the facility’s policy concerning this issue. The smoking policy should be written clearly without ambiguity and be communicated to residents, staff and visitors. While safety should be a primary consideration with regards to developing an effective smoking policy, resident rights should also be protected to the greatest extent possible. Facilities needing help or assistance developing smoking policies may want to contact their local long term care ombudsman or contact the State Long Term Care Ombudsman’s office at (919) 733-8395.
- Cognitive status and supervision – In many cases involving fires in nursing and adult care facilities, the issue of adequate supervision is most often cited as the reason for smoking related fires. Residents with deficits or recent changes in memory and/or judgement need to be assessed to determine how much supervision they will require when smoking. Residents with cognitive deficits will typically require more supervision when smoking than residents who do not have cognitive deficits. In addition, residents who are cognitively intact who, on the surface, appear they can smoke with little supervision may require more supervision if they are prone to provide smoking materials to residents who would typically require a high level of supervision when smoking. Supervision may also include evaluation of whether or not the resident can retain their own cigars, cigarettes, matches, lighter, etc., or if the facility should retain these items to distribute for use upon request.
- Oxygen-enriched atmospheres (areas) –precautions must be taken in oxygen-enriched atmospheres. Oxygen-enriched atmospheres include areas in which an oxygen delivery device has been connected to a flowmeter and the flowmeter is in the “on” mode, i.e. resident receiving oxygen via nasal canula, oxygen mask or other delivery device. According to the NFPA-99, once a device is connected to the flowmeter, the measures listed (below) would need to be followed:
- 9.6.1.1 Elimination of Sources of Ignition. It is very important that visitors be informed of a facility’s policies so as not to jeopardize the safety of patients, other visitors, and staff through prominent posting of signs.
- 9.6.2.1.1 Smoking materials (matches, cigarettes, lighters, lighter fluid, tobacco in any form) all be removed from patients receiving respiratory therapy and from the area of administration. A policy on smoking should be developed for the entire facility to avoid confusion and to generally reduce the hazard from smoking.
- 9.6.1.1.2 No sources of open flame, including candles, shall be permitted in the area of administration.
- 9.6.3.2.1 In health care facilities where smoking is not prohibited, precautionary signs readable for a distance of 5 ft shall be conspicuously displayed wherever supplemental oxygen is in use and in aisles and walkways leading to that area; they shall be attached to the adjacent doorways or to building walls or supported by other equipment.
- 9.6.3.2.2 In health care facilities where smoking is prohibited and signs are prominently (strategically) placed in all major entrances, secondary signs with NO Smoking language shall be required.
- NFPA-99 Chapter 3, Definitions section 3.3.13 defines area of administration (as noted above) as: “Any point within a room within 15 ft (4.3m) of oxygen equipment or an enclosure containing or intended to contain an oxygen-enriched atmosphere.”
Therefore, according to NFPA-99 guidelines, smoking materials and any other source of ignition should be kept at least 15 ft. (4.3 m) away from an oxygen-enriched atmosphere such as a resident receiving oxygen via nasal canula, oxygen mask or other delivery device.
It should be noted it is not the policy of the State to discourage facilities from allowing residents to smoke. However, when residents do smoke, it is imperative that the facility consider the amount and level of supervision the resident may need for this activity and other considerations, such as a resident that smokes and who uses oxygen, that would warrant further precautionary measures be taken.
If there are further questions concerning this issue, please do not hesitate to contact (919) 855-4520 for questions related to nursing facilities and (919) 855-3784 for questions related to adult care facilities.
NC Fire Prevention Code - 2006 Edition
310.1 General. The smoking or carrying of a lighted pipe, cigar, cigarette or any other type of smoking paraphernalia or material is prohibited in the areas indicated in this section.
310.2 Prohibited areas. Smoking shall be prohibited where conditions are such as to make smoking a hazard, including areas of piers, wharves, warehouses, stores, industrial plants, institutions, schools, assembly occupancies and in spaces where combustible materials are stored or handled, except in approved designated smoking areas.
310.3 "No Smoking" signs. The code official is authorized to order the posting of “No Smoking” signs in a conspicuous location in each structure or location in which smoking is prohibited. The content, lettering, size, color and location of required “No Smoking” signs shall be approved.
310.4 Removal of signs prohibited. A posted “No Smoking” sign shall not be obscured, removed, defaced, mutilated or destroyed.
310.5 Compliance with "No Smoking" signs. Smoking shall not be permitted nor shall a person smoke, throw or deposit any lighted or smoldering substance in any place where “No Smoking” signs are posted.
310.6 Ash trays. Where smoking is permitted, suitable noncombustible ash trays or match receivers shall be provided on each table and at other appropriate locations.
310.7 Burning objects. Lighted matches, cigarettes, cigars or other burning object shall not be discarded in such a manner that could cause ignition of other combustible material.
310.8 Hazardous environmental conditions. When the code official determines that hazardous environmental conditions necessitate controlled use of smoking materials, the ignition or use of such materials in mountainous, brush-covered or forest-covered areas or other designated areas is prohibited except in approved designated smoking areas.