Failure to Reassess Resident After Multiple Indoor Smoking Incidents
Penalty
Summary
The facility failed to ensure that a resident who had multiple incidents of smoking indoors was reassessed for safe smoking, as required by policy. The resident, who was cognitively intact and independent with activities of daily living, had a care plan and assessment indicating she was a safe smoker and only smoked in designated areas. However, progress notes documented at least three separate incidents over a period of 6-7 months where the resident was found smoking in her room, in violation of the facility's smoking policy. On each occasion, the resident was educated on the risks and signed the smoking policy, but no reassessment for safe smoking was conducted. Observations showed the resident kept a significant number of cigarettes and a lighter at her bedside. Staff interviews confirmed awareness of the resident's indoor smoking incidents and indicated that, while staff would sometimes hold onto smoking materials and provide education, the resident was still able to access her own cigarettes. The social services designee and DON both acknowledged that a reassessment should have occurred after the incidents, but it was not completed. The facility's policy required immediate action and reporting when indoor smoking was observed, but this was not fully implemented in the resident's case.