Failure to Perform Quarterly Safe Smoking Assessments and Secure Smoking Materials
Penalty
Summary
The facility failed to perform required quarterly safe smoking assessments and did not secure smoking materials, specifically a vaping pen, for one resident. According to the facility's smoking policy, residents are not permitted to keep smoking-related materials, including electronic smoking devices, on their person or in their rooms when not smoking. The policy also requires quarterly evaluations by the interdisciplinary team to assess residents' ability to smoke safely. However, the facility missed quarterly safe smoking assessments for some residents, including the resident involved in this incident, due to a system changeover that cleared assessment schedules. A resident with a history of type 2 diabetes, cerebral infarction without residual deficits, and nicotine dependence was assessed as a safe smoker and allowed to smoke or vape independently. The resident was observed vaping in the doorway of her room, which is a non-smoking area, and admitted to keeping a vaping pen on her person. She stated she was aware of the policy prohibiting smoking or vaping in her room and acknowledged that the facility was unaware she had the vaping pen in her possession. The resident also had access to a locker in the courtyard for storing smoking supplies but kept the key and vaping pen with her in her room, contrary to facility policy. Staff interviews confirmed that the resident had not been observed smoking or vaping inside the facility prior to this incident. The facility's unit manager and administrator were unaware that the resident had vaping materials in her room until informed by the surveyor. The administrator later confirmed that quarterly safe smoking assessments were missing for some residents, including the one involved, due to an electronic charting system issue during a company transition.