Failure to Update Smoking Assessment and Care Plan
Penalty
Summary
The facility failed to conduct a smoking assessment and revise the care plan for a resident who resumed smoking. The resident, who has a history of type 2 diabetes mellitus, cerebral infarction, and liver cancer, was admitted to hospice care in February 2025. Despite being cognitively intact, the resident's electronic medical records did not reflect a current smoking assessment or care plan, even though the resident had signed a smoking contract in April 2024. The facility's policy requires smoking assessments to be performed upon admission, quarterly, or with any changes affecting the resident's safety, but this was not adhered to when the resident resumed smoking. Interviews with facility staff revealed a lack of awareness regarding the resident's current smoking status. The Social Service Assistant and Director were unaware that the resident had resumed smoking, despite the resident's own admission and observations of the resident smoking outside the facility. The resident's smoking activities were facilitated by a hospice volunteer and nursing staff, who provided access to cigarettes and a lighter. The facility's policy mandates that all residents desiring to smoke must have a smoking assessment and care plan developed by the interdisciplinary team, which was not updated in this case, leading to the deficiency.