Residents Left Unsupervised During Smoking Sessions
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for three residents who were left unsupervised while smoking cigarettes in the designated smoking area. Resident 7, who had moderate cognitive impairment, muscle weakness, and mobility issues, was observed smoking without staff supervision. Resident 8, also with moderate cognitive impairment, hemiplegia, vascular dementia, and a history of falls, was similarly left unsupervised. Resident 9, who had intact cognition but significant physical disabilities including hemiplegia and speech disorders, was also present without the required 1:1 observation as indicated in their care plan. All three residents were observed smoking on the patio for at least 15 minutes without staff present, contrary to their care plans and facility policy. Interviews with staff confirmed that some residents do not comply with the smoking policy or their individual care plans, and that the three residents observed had not signed out of the facility as required for unsupervised smoking. The facility's policy specifies that smoking may only occur with staff present and during designated times, but these procedures were not followed. The lack of supervision during smoking sessions created a potential for burn injuries and fire hazards, as noted in the findings.