Failure to Supervise Smoking and Prevent Smoking-Related Hazards
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for residents who smoke, resulting in multiple deficiencies related to smoking safety. Several residents who required supervision with smoking, as indicated by their care plans and smoking assessments, were found to have unsupervised access to cigarettes and lighters. In one incident, a resident with a history of noncompliance with the smoking policy was able to smoke in bed, resulting in burned linens while three roommates were present in the room. The facility was unaware that this resident had retained smoking materials in his possession, and the incident required intervention by staff and notification of police. Other residents with documented needs for supervision were observed with cigarettes and lighters in their possession, both in their rooms and in the designated smoking patio. Despite care plans specifying that smoking materials should be kept at the nurses' station and that residents should be supervised while smoking, staff interviews revealed a lack of awareness regarding residents' possession of these items. Some staff members stated that residents are not allowed to have lighters due to fire and safety concerns, especially with the presence of oxygen in the facility, but acknowledged that some residents still retained these items. Additionally, the facility did not consistently conduct Interdisciplinary Team (IDT) meetings to assess the risks and benefits of smoking for all residents who smoke, as required by facility policy. Only a minority of residents who smoked had attended such meetings, and some residents did not have care plans addressing smoking safety. These failures resulted in unsafe conditions for residents, staff, and visitors, as evidenced by the smoking-related incident and the observed lapses in supervision and policy adherence.