Failure to Provide Safe, Designated Smoking Areas and Supervision
Penalty
Summary
The facility failed to follow its own smoking policy by not providing a safe, designated smoking area for nine of 27 sampled residents. Observations revealed that multiple residents were smoking on the sidewalk or driveway adjacent to busy roads and parking lots, rather than in a designated, supervised area as required by facility policy. Several residents were seen in potentially hazardous locations, such as crossing multiple lanes of traffic or sitting near high-traffic areas, without staff supervision or the required safety equipment. Some residents were also found in possession of lighters and cigarettes, despite the policy stating that such materials should be stored by the facility. Record reviews showed that many residents had care plans and smoking assessments indicating they required constant supervision while smoking, yet they were allowed to sign out on a Leave of Absence (LOA) and smoke unsupervised in unsafe areas. In some cases, the documentation on the LOA sign-out sheets did not match the observed times residents were outside smoking, indicating a lack of accurate tracking. Additionally, at least one resident had not signed the required Smoking Agreement/Notice of Policy, and staff interviews revealed confusion and inconsistency in the implementation of the smoking policy, including errors in smoking assessments and a lack of communication about safety concerns related to smoking near the road. Interviews with staff and residents highlighted further issues, such as staff being pulled from other duties to supervise smoking breaks, leading to delays in resident care. Some staff were unaware of the specific safety risks associated with residents smoking near busy roads, and there was a lack of clear guidance provided to residents about where they could safely smoke. The facility's failure to enforce its smoking policy and ensure proper supervision and designated smoking areas directly contributed to the observed deficiencies.