The Lighter in the Bathrobe Pocket
Mr. Delgado is 84, has moderate dementia and COPD, and wears nasal cannula oxygen at 2 L/min continuously. While straightening his room you see a cigarette lighter in his bathrobe pocket. He says his daughter brought it and asks you to help him go outside for 'just one cigarette.' The facility and its grounds are smoke-free, and his roommate is also on oxygen. When you say no, Mr. Delgado's voice rises and he begins pushing his walker toward the door. You are the only CNA on a 12-resident hall, and the nurse has just left for a 15-minute break.
1. What are your first actions in the next few minutes, and what must you avoid doing?
Read the worked answer
Act on the fire risk first, then the behavior.
- An ignition source plus flowing oxygen is an immediate fire hazard for him, his roommate, and you. Do not leave the room or turn your back while the lighter is in his pocket.
- Ask once, calmly and privately: 'Mr. Delgado, I need to keep the lighter safe until we sort this out.' If he hands it over, put it in the locked medication/storage area per facility policy and tell the nurse.
- If he refuses, do not dig into pockets or pry a clenched hand open. A physical struggle next to oxygen tubing is more dangerous than the lighter. Step back, stay within sight, and summon the nurse by call light or radio despite the break.
- Redirect: walk with him toward the door or hallway (he is already up), offer coffee, a snack, or a task. Do not argue about the smoke-free rule in the moment; it is not negotiable and arguing escalates.
- Never say 'you can smoke later' if that is false.
2. What do you report, to whom, and how do you document it?
Read the worked answer
Report immediately and factually. Tell the nurse: the lighter was found in his pocket, the daughter reportedly supplied it, he requested to go outside to smoke, he became agitated and headed for the door, and the lighter is either secured or still on his person (say which).
Reporting is not optional because the nurse must decide on pocket checks, nicotine replacement orders, and a family conversation. A CNA should never promise secrecy or handle a repeated pattern alone.
Documentation sticks to observable facts and direct quotes: 'Lighter observed in resident's bathrobe pocket at 0815. Resident stated, "My daughter brought it." Resident raised voice and moved toward door with walker. Nurse notified at 0817. Lighter secured in medication room.'
Avoid labels like 'combative,' 'manipulative,' or 'noncompliant.' Those are conclusions, not observations, and they follow the resident in the record.
3. How would you protect his dignity and independence while keeping the unit safe?
Read the worked answer
Smoking is a legal adult choice, and Mr. Delgado's dementia does not erase his preference; it does change what supervision looks like.
- Do not shame him, lecture him in front of his roommate, or announce the lighter to the hall.
- Separate the person from the risk: 'You are not in trouble. Oxygen and flames cannot be in the same room, so we have to make a plan with the nurse.'
- Ask the nurse about nicotine replacement, a scheduled smoke break off grounds with supervision if the facility allows it, or a care-plan meeting that includes his daughter so she understands why supplying a lighter is unsafe.
- Offer choices he can genuinely make (where to walk, what to drink, when to sit) so the day is not a series of refusals.
- Ask for a social work or activities referral to address the craving and boredom behind the request.