Inadequate Supervision and Policy Enforcement for Resident Smoking
Penalty
Summary
The facility failed to provide adequate supervision for residents who smoke, as evidenced by multiple incidents involving three residents. Resident R24 was repeatedly found smoking in non-designated areas and times, despite being re-educated on the facility's smoking policy. The facility's policy stated that smoking inside the building was prohibited, and violations could lead to revoked smoking privileges and potential discharge. However, despite numerous infractions, including smoking in his room and possessing smoking materials, the facility did not enforce these consequences, and documentation of these incidents was lacking. Additionally, Resident R5 was observed in the designated smoking area with an oxygen cylinder attached to his wheelchair, which violated the facility's policy prohibiting oxygen cylinders in the smoking area due to fire hazards. This incident occurred without staff supervision, as required by the facility's smoking policy. Resident R63 was also found smoking outside the designated times and without supervision, and it was revealed that he had not been informed of the smoking policy or signed a smoking agreement upon admission. The facility's failure to enforce its smoking policy and provide adequate supervision created potential safety hazards, particularly concerning the risk of fire. The lack of documentation and enforcement of consequences for non-compliance with the smoking policy contributed to the ongoing issues with resident smoking behavior. Interviews with staff and residents confirmed these deficiencies, highlighting the facility's inadequate management of smoking-related risks.
Plan Of Correction
1. An Ad Hoc QAPI meeting was immediately conducted to update the smoking policy and its enforcement. The new smoking policy allows for more smoking times for residents deemed safe to improve residents compliance and enforcement of the policy. Residents were educated that any violation of the smoking policy will result in immediate action with potential for 30 day discharge notice to be given. R24 was educated on the new smoking policy and was informed that he will not be able to keep cigarettes on his person. R5 was reassessed and it was determined that he should be on oxygen PRN. He was educated that he may not go outside to smoke with a oxygen tank on him. R63 was reeducation on the new smoking policy. 2. A Full house audit on all residents identified as smokers was done to ensure they are aware of the policy and that there no others identified smokers. 3. Staff will be educated on the components of this regulation with an emphasis on accident prevention, supervision, and appropriate use of devices. 4. 5 residents who smoke will be audited to ensure they understand the smoking policy and are being properly supervised 1x a week for 1 month, 2x a month for 1 month and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.