Failure to Assess Resident for Smoking Safety
Penalty
Summary
The facility failed to properly assess a resident, identified as Resident R52, for smoking safety, which is a requirement under §483.25(d) to ensure the resident environment remains as free of accident hazards as possible. The facility's policy mandates that during the admission process, residents are asked about their smoking habits and intentions, and those who affirmatively respond are further assessed for smoking safety awareness. This assessment is also required on readmission, quarterly, and with any significant change in the resident's condition. However, the Smoking Risk form completed on 10/8/24 incorrectly stated that Resident R52 does not smoke and intends to remain non-smoking, despite the resident's clinical record indicating nicotine dependence and current tobacco use. Interviews with Resident R52 and the Registered Nurse Assessment Coordinator (RNAC) confirmed that the resident is indeed a smoker, who smokes three times a day. This discrepancy highlights the facility's failure to accurately assess and document the resident's smoking status, which is crucial for ensuring adequate supervision and safety measures are in place to prevent accidents. The oversight was acknowledged by the RNAC, who confirmed the facility's failure to properly assess the resident's smoking risk on the specified date.
Plan Of Correction
Resident #52 was assessed for smoking safety awareness and safety accommodations are implemented. To identify other residents that have the potential to be affected, the DON/designee completed an audit of current residents to ensure residents have smoking assessments that reflect current status and reasonable safety accommodations are implemented as needed. Corrections will be made as needed. To prevent this from recurring, the RDCS provided education to licensed nursing on the requirements of completing smoking assessments on the need to implement safety accommodations. To monitor and maintain ongoing compliance, the NHA/designee will audit 3 residents weekly x4, then monthly x2 to ensure smoking assessments are completed per policy to reflect resident current status and that safety accommodations are implemented as indicated. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.