Failure to Conduct Smoking Assessment for Resident
Penalty
Summary
The facility failed to conduct a smoking assessment for a resident identified as a smoker, leading to a deficiency in ensuring a safe environment. The resident, who was included in the facility's smoking list and had smoking privileges, was found on the floor after attempting to smoke secretly in the bathroom. Despite being identified as a smoker, the resident's clinical records did not contain any evidence of a smoking safety assessment or a smoking care plan. Interviews with facility staff confirmed the oversight. The Activities Director acknowledged that the resident was a smoker and had been educated not to smoke in his room, yet no formal assessment or care plan was in place. The Director of Nursing also confirmed the absence of a smoking safety assessment for the resident, which is a requirement for residents who wish to smoke. This lack of assessment and planning contributed to the resident's fall and the potential for further accidents.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. R14 was reassessed and has an updated smoking assessment and care plan. The DON/designee conducted an audit of residents on the smoking list to ensure smoking assessments are accurate and that care plans are in place. The DON/designee educated licensed staff on ensuring that residents that smoke have an accurate smoking assessment and a care plan. The DON/designee will audit the smoking list to ensure any new smokers added to the list have an appropriate assessment and a care plan. Audits will be done weekly x 4 weeks and monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.