Failure to Provide Required Supervision for Residents During Smoking Activities
Penalty
Summary
The facility failed to ensure that residents assessed as needing constant supervision while smoking received adequate supervision. Multiple residents, all identified as smokers with various medical conditions such as COPD, diabetes, muscle weakness, amputations, and cognitive impairments, were observed smoking outside the facility without staff supervision. Some residents were seen smoking on sidewalks adjacent to busy roads and driveways, with traffic moving at high speeds, and in areas not designated as safe smoking locations. Several residents had access to lighters and cigarettes, contrary to facility policy requiring these items to be stored by staff. Record reviews revealed that these residents had care plans and smoking assessments indicating a need for constant supervision while smoking. However, staff interviews and observations confirmed that residents were allowed to sign out on Leave of Absence (LOA) and smoke unsupervised in potentially hazardous areas. The facility's own policies required supervision for residents assessed as needing it, but staff reported confusion and errors in completing smoking assessments, and there was a lack of clear communication regarding safe smoking locations and supervision requirements. Some residents had not signed the required smoking policy agreement, and documentation of LOA times was inconsistent with actual resident whereabouts. Staff interviews further revealed that the facility struggled to keep track of residents' smoking materials and LOA cards, and that supervision during smoking times was inconsistent, sometimes pulling aides away from other resident care duties. The facility's designated smoking policy and procedures were not consistently followed, leading to unsupervised smoking by residents who required supervision according to their assessments and care plans.