Oxygen and a Lighter at 6:40 am
It is 6:40 am on a long-term care unit. Mr. Pruitt, 82, has COPD and wears a nasal cannula at 2 L/min around the clock. He uses a walker and is alert and oriented. He rings his call light and announces, "I'm going out for a cigarette. I've smoked for sixty years and nobody's stopping me today." He pulls a lighter and a pack of cigarettes from his robe pocket. The designated smoking area is outside, about 200 feet and two fire doors away. Facility policy requires that oxygen be shut off and the resident escorted by staff before anyone smokes. The other aide on the floor is in a shower room with a resident and cannot be summoned instantly.
1. What do you do in the next five minutes?
Read the worked answer
This is an immediate fire-risk situation, so safety outranks courtesy - but it is handled with respect, not a wrestling match.
- Do not leave him alone and do not let him light anything. Oxygen saturates clothing, hair, and bedding; a flash fire in a room with an oxygen concentrator can kill him and everyone on the hall.
- Ask for the lighter directly and explain why: "Mr. Pruitt, I'm not trying to take your cigarettes away. I can't let you light up while you're wearing oxygen - the oxygen soaks into your robe and it will catch fire. I need the lighter while you're on oxygen." If he hands it over, secure it per facility policy (usually labeled and stored, not thrown out).
- Call for help using the call light or phone to get the nurse or another staff member to the room.
- Offer the legitimate path: "If you want a cigarette, the nurse can shut your oxygen off, and I or another aide will walk out with you to the smoking area. That's allowed. What isn't allowed is lighting up in this room."
- If he heads for the door anyway, stay with him, keep him talking, and get the nurse - do not block the doorway physically or grab him.
The goal is a resident who is off oxygen and escorted outside, not a resident who is cornered in his room.
2. What do you report, to whom, and what goes in the chart?
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Report immediately to the nurse - this is a safety event, not a note for the end of shift. Tell her: what he said, that he had a lighter and cigarettes in his pocket, whether he surrendered them, that he was educated about oxygen and fire, that he remains insistent on smoking, and what assistance he needs to smoke safely.
Chart objectively:
- Time, direct quote ("I'm going out for a cigarette").
- "Lighter and cigarettes in robe pocket observed."
- "Explained fire risk of smoking while on oxygen. Resident states he has smoked 60 years and intends to smoke."
- What was done with the items, per policy.
- "Nurse notified at ____."
- Any behavior, not character judgment - "agitated, voice raised," not "belligerent."
Do not write "resident refused smoking cessation" as though he had been ordered to quit, and do not write your opinion that he is a fire hazard. Facts, times, notifications.
3. What should change before the next shift so this does not happen again?
Read the worked answer
A rule that only exists at 6:40 am is not a plan. Several things need to move:
- Ask the nurse for a care plan update that spells out how smoking is handled: oxygen off, time limit, staff escort, where the lighter is kept, and who checks pockets. A wandering resident with a lighter is a building-wide risk.
- Check the room for ignition sources - lighters, matches, and any smoking materials in the bedside drawer or under the mattress - with the resident's knowledge, not as a secret search.
- Anticipate the craving. Ask when he usually smokes; offering an escorted trip at a predictable time prevents the 6:40 am standoff. Also assess for nicotine withdrawal (irritability, restlessness) and mention it to the nurse.
- Offer cessation information without a lecture - he is entitled to decline it.
- Tell the next shift verbally what happened, not just via the chart.
Document the plan and the notification, so the next aide is not improvising at the door with a lighter.