Failure to Secure Smoking Materials in Accordance with Facility Policy
Penalty
Summary
The facility failed to ensure that smoking materials were stored in a safe and secure location, as required by facility policy, affecting two residents identified as independent smokers. Both residents were permitted to smoke independently and were observed to keep their smoking materials, including cigarettes, lighters, and a vape cartridge, in their rooms rather than in the designated locked storage as outlined in the facility's smoking policy. Multiple staff interviews revealed uncertainty and inconsistency regarding the enforcement of the policy, with some staff unsure whether independent smokers were allowed to keep their smoking supplies in their rooms. For one resident, who had diagnoses including encephalopathy, alcohol dependence with persisting dementia, and tobacco use, observations revealed a strong odor of smoke in the resident's room, a vape cartridge found on the floor near an oxygen concentrator, and confirmation from the resident that she kept her smoking materials in her room or coat pocket. Staff interviews confirmed that smoking materials were supposed to be locked in the medication cart, but this was not being followed for this resident. The resident's care plan and signed smoking agreement both required that smoking materials be locked up, but these interventions were not implemented. Similarly, another resident with a history of alcohol and nicotine dependence and a cognitive communication deficit was also found to keep smoking materials in his room, contrary to facility policy. Staff interviews and observations confirmed that this resident, too, was not following the policy requiring smoking materials to be locked up. Both residents' care plans and signed agreements specified that smoking materials should be secured, and any infraction would result in loss of smoking privileges, but these measures were not enforced. The facility's own policy and procedure documents reiterated the requirement for locked storage of smoking materials, which was not adhered to in these cases.