Deficiency in Facility-Wide Assessment for Smoking and Cultural Needs
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment that adequately addressed the needs of residents who smoke and the cultural needs of the Asian American population. The deficiency was identified through observations, interviews, and document reviews. The Licensed Nursing Home Administrator (LNHA) provided smoking hours and a list of residents who smoke, but the facility's smoking policy was insufficiently documented as it was only represented by a 'Smoking Rules and Agreement' document. Staff interviews revealed a lack of clarity and consistency in the smoking process, with discrepancies in who was responsible for holding residents' cigarettes and lighters. Additionally, there was confusion about the existence and location of a list of residents requiring smoking aprons, indicating a lack of staff knowledge and a formalized smoking policy. The facility also failed to address the cultural needs of its Asian American residents. A family member of a resident expressed concern about the lack of a daily Korean newspaper, which was supposed to be provided. Although the facility had menus and activity calendars in Chinese, there was no clear process or responsibility for ensuring the delivery of culturally appropriate materials, such as the Korean newspaper. The Activities Director was aware of the resident's needs but was unsure who was responsible for providing the newspaper. The facility assessment tool did not adequately address these cultural needs, highlighting a gap in the facility's ability to provide culturally competent care.
Plan Of Correction
Rose Mountain Care Center Facility ID: 3145384 Survey completion date: 12-12-2024 **F838 SS-E Facility Assessment** **Element One:** All staff were immediately educated on the smoking policy and process. A newspaper was immediately ordered for the resident. The facility assessment was updated ensuring all resources necessary for the care of the residents are documented. **Element Two:** All residents who smoke and the residents from the Asian population had the potential to be affected by the deficient practice. **Element Three:** All staff were educated regarding the facility's smoking policy and process. The activity staff and admissions staff were educated to inform the administrator if there are any delays in the newspaper being delivered. The facility Administrator was educated by the Regional Administrator on the facility assessment requirements and ensuring all resources necessary for the care of the residents are documented. The residents were explained the importance of smoking safety and following the rules. They were educated about not holding their cigarettes and lighters as well as the designated smoking times. The residents were also educated on the facility's smoking policy and process. **Element Four:** The Administrator/designee will continue to monitor the smoking program to ensure safety. The Administrator will review the facility assessment monthly for 3 months, then quarterly, as well as updating it on an as-needed basis. Results will be reported to the QAPI team for review. Completion Date: 12-25-2024