Failure to Update Smoking Safety Evaluation for Resident
Penalty
Summary
The facility failed to ensure a current smoking assessment for a resident diagnosed with Multiple Sclerosis, major depressive disorder, and unspecified dementia. The resident, who is alert and oriented, reported leaving the premises to smoke in accordance with the facility's Smoking Agreement. This agreement stipulates that the resident must leave the property to smoke, not share smoking materials with other residents, and sign in and out for leave of absence as per policy. A review of the resident's clinical record revealed that the last Smoking Safety Evaluation was conducted in July 2023, with no subsequent evaluations completed. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the absence of a current Smoking Safety Evaluation for the resident since July 2023. This deficiency was previously cited in March 2024, indicating a recurring issue with management oversight.
Plan Of Correction
1. Resident 24 smoking assessment was completed. 2. Facility audit completed and no other residents at risk. 3. DON, or designee, will educate licensed staff regarding smoking assessment needing completed monthly for resident 24. 4. DON, or designee, will perform audits monthly and as needed on resident 24 for completion of smoking assessment. Results of audits will be submitted to monthly QAPI for review and recommendations.