Failure to Implement Smoking Safety Procedures and Timely Assessments
Penalty
Summary
The facility failed to implement and follow its own procedures for smoking safety, as evidenced by the lack of timely smoking safety assessments and incomplete care planning for three residents who smoke. According to the facility's Resident Smoking Policy, residents who choose to smoke must be assessed for smoking safety awareness upon admission, readmission, quarterly, and with any significant change in condition. However, clinical record reviews showed that these assessments were not completed within the required 90-day intervals for all three residents sampled. Specifically, one resident went 138 days without reassessment, another 158 days, and the third 100 days, all exceeding the policy's quarterly requirement. Additionally, the care plan for one resident who was identified as a smoker did not include any interventions or address safe smoking practices, despite the resident's status and the facility's policy. The Director of Nursing confirmed these lapses, acknowledging that the facility did not ensure residents were assessed and monitored for smoking safety as required. These findings were based on clinical record reviews, policy review, and staff interviews.