Failure to Maintain a Smoke-Free Environment for Resident
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for Resident 26, who was observed smoking a cigarette in the facility parking lot despite the facility's policy of being a smoke and tobacco-free campus. Resident 26, who has chronic obstructive pulmonary disease and normal pressure hydrocephalus, was seen smoking next to an employee, indicating a lack of supervision and adherence to the facility's smoking policy. The resident's clinical records did not include a smoking evaluation for safety, nor was there a care plan addressing safety while smoking. Interviews revealed that Resident 26 kept cigarettes and a lighter in her room without a secure place to store them, posing a potential risk to other residents. The facility was aware of the resident's smoking habits and required her to leave the grounds to smoke, but employees were not permitted to assist her during work hours. This lack of a structured plan and supervision for Resident 26's smoking activities contributed to the deficiency in maintaining a hazard-free environment.
Plan Of Correction
Resident 26 will be evaluated for safety with smoking. She will be offered a lock box for her room to keep her cigarettes and lighter in. A care plan will be developed ensuring residents' safety while smoking. All residents requesting to smoke off facility property will have a safety evaluation completed. Storage will be provided for cigarettes and cigarette lighting devices. A care plan will be developed to ensure resident safety while smoking. Facility smoking policy has been updated to include resident assessment for safety with smoking, providing proper storage of cigarettes and cigarette lighting devices, and care plan development to ensure safety. All facility staff will be updated on the revised policy. Staff will be educated that they are not permitted to assist residents with smoking while clocked in to work. A QA tool has been developed to review all residents that smoke weekly to ensure policy compliance. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.