Failure to Develop and Implement Smoking Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's smoking needs, despite policy requirements that any smoking-related privileges, restrictions, and concerns be documented in the care plan. The resident in question was moderately cognitively impaired, required assistance with mobility and transfers, and had multiple diagnoses including cancer, chronic lung disease, malnutrition, and muscle weakness. A smoking evaluation indicated the resident required supervision and assistance to light or extinguish cigarettes. Record review revealed that no care plan for smoking was present in the resident's electronic health record, even though the resident reported smoking occasionally and staff confirmed that the resident smoked under supervision. The absence of a care plan was acknowledged by the Regional MDS Coordinator, who noted that an assessment had been completed but a care plan was not generated as required.