Failure to Conduct Smoking Safety Assessments
Penalty
Summary
The facility failed to assess three residents for safe smoking practices, as required by their own policy. The policy mandates that smokers be reviewed on admission, at least quarterly, and as necessary depending on individual circumstances and changes in the resident's condition. However, the facility did not adhere to this policy for Residents R4, R10, and R54. Resident R4, who has a history of atrial fibrillation, seizures, and cognitive communication deficit, was last assessed for smoking safety on 12/22/23, despite the care plan indicating a need for regular reviews. Resident R10, with diagnoses of diabetes, asthma, and heart failure, was last assessed on 7/2/24, and Resident R54, with diabetes and high blood pressure, was last assessed on 8/20/24. The Director of Nursing confirmed during an interview that no further assessments were completed for these residents as required. The failure to conduct these assessments is a violation of the facility's smoking policy and the regulatory requirement to ensure the resident environment remains as free of accident hazards as possible. This oversight could potentially expose residents to risks associated with smoking, given their medical conditions and the lack of updated safety assessments.
Plan Of Correction
The facility will ensure residents are assessed for safe smoking. A smoking assessment will be completed for residents R4, R10, and R54 to ensure it is current and the resident is safe to smoke. A house audit will be completed to validate residents who smoke have a current smoking assessment completed. The Director of Nursing or Designee will re-educate licensed nurses, including new hires and agency, on the facility policy and procedures for Smoking, detailing completing safe smoking assessments for residents who wish to smoke. The Director of Nursing or Designee will complete an audit weekly for four weeks, then monthly for three months, to validate residents who smoke have a current and accurate smoking assessment. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.