Resident Smoking Supervision Deficiency
Penalty
Summary
The facility failed to ensure adequate supervision for a resident while smoking, leading to a deficiency in maintaining a safe environment. Resident 5, who was admitted with conditions including cerebrovascular disease, right side hemiplegia, and glaucoma, was observed smoking unsupervised near the facility's parking lot. The resident, who was forgetful and unable to make reasonable decisions, was seen without a smoking apron or a safe receptacle for cigarette disposal. Despite the care plan indicating the need for supervision and the use of protective measures, the resident was left alone, posing a risk of burn injuries. Interviews with facility staff revealed a lack of awareness and supervision regarding Resident 5's smoking activities. A Licensed Vocational Nurse mentioned that smoking supplies were kept at the nursing station and provided to residents when needed, but the resident was still found smoking alone. A Certified Nursing Assistant admitted to being unaware of the resident's unsupervised smoking due to being occupied with other duties. The Director of Nursing acknowledged that all staff were responsible for ensuring resident safety during smoking. The facility's policies required smoking to occur in designated areas with appropriate safety measures, which were not adhered to in this instance.
Plan Of Correction
Free of Accident Hazard / Supervision / Devices CFR(s): 483.25(d)(1)(2) Corrective action: • The body check was done on Resident 5 on 3/6/25 RN Supervisor and Tx nurse with no indication of cigarette burns and other skin issues associated with smoking. • SSD spoke with Resident 5 and Brother on 3/7/25 regarding Smoking Policies giving emphasis that cigarettes and lighter will be kept by LN, smoking schedule that is supervised by staff. How to identify potentially affected other: • RN supervisor made rounds on 3/6/25 and there was no other resident smoking. • Medical Records audited current residents who desired to smoke and non-compliance regarding facility's smoking policy was audited on 3/21/25 to ensure that smoking assessment & care plan are updated and revised in resident's record. No issues were identified. Measures/Systemic change: • License Nurses and Certified Nurse Assistant was given in-service by Director of Nursing regarding Smoking Resident on 3/6/25, 3/7/25, 3/7/25, 3/8/25, 3/11/25 and 3/12/25 giving emphasis on following smoking schedule, making sure that all cigarette & lighter should be kept by LN, smoking resident should be assessed with care plan and should be supervised by assigned staff at all times. • IDT was done on 3/24/25 by SSD to all current residents who smoke giving emphasis on smoking schedule with staff to supervised and all cigarette & lighter should be kept by LN. Monitoring: • Nursing staff will monitor daily rounds on their shift to ensure "no cigarette lighter permitted in the resident's room for the resident who desire to smoke. Any issues identified will be corrected. • The SSD will conduct random weekly rounds for 1 month, then 3 months and then quarterly thereafter or until compliance is reached and ongoing as needed to ensure the appropriate storing of cigarette, lighter for the resident who desired to smoke. Any issues identified will be corrected. • DON and or designee will randomly check for compliance. • Audit review the Smoking progress report, will be discussed and reported in the monthly QA & A meeting for further intervention and compliance. Completion Date: 3/26/25