Failure to Include Smoking Status in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including a history of transient cerebral ischemic attacks, cerebral vascular disease, hyperlipidemia, hypertension, and muscle weakness. The resident was assessed as having moderate cognitive impairment and was dependent on staff for most activities of daily living. Despite documentation in the resident's records and a smoking assessment indicating the resident was a smoker and required adaptive equipment such as a smoking apron, the comprehensive care plan did not include any interventions or objectives related to the resident's smoking status. Observations confirmed that the resident was actively smoking in the designated area while using a smoking apron, and interviews with both the resident and staff corroborated the resident's smoking status and the use of adaptive equipment. The MDS nurse acknowledged that it was her responsibility to include smoking in the care plan and admitted to overlooking this requirement, which resulted in the absence of a care plan addressing the resident's smoking needs. The facility's own policy requires that care plans include measurable objectives and timeframes for all identified needs, but this was not followed in this case.