Failure to Re-Assess Resident for Safe Smoking Behaviors Prior to Smoking
Penalty
Summary
The facility failed to ensure that a resident was properly re-assessed for safe smoking behaviors before being allowed to smoke, despite initial admission documentation indicating the resident did not use tobacco products. Upon admission, the resident was evaluated and marked as a non-smoker, which led to the smoking assessment being stopped. However, subsequent progress notes and medication records showed that the resident expressed a desire to smoke, was observed preparing to smoke, and was ultimately provided cigarettes and allowed to smoke with staff supervision. The resident also had a nicotine patch prescribed and later discontinued due to active smoking. Despite the facility's policy requiring assessment for safe smoking behavior prior to granting smoking privileges, the resident was permitted to smoke before a re-assessment was completed. The care plan and smoking assessment were only updated after the resident had already been observed smoking. Interviews with facility leadership revealed uncertainty about whether residents were assessed before being allowed to smoke, and documentation confirmed that the resident was not re-assessed for smoking safety until after smoking had occurred.