Failure to Assess and Supervise Resident Vape Use
Penalty
Summary
A deficiency was identified when a resident was observed keeping a vape (electronic cigarette) on her over bed table, with no documentation that she had been evaluated for safe use of the device. The resident, who had diagnoses including hemiplegia, hemiparesis, type 2 diabetes with neuropathy, and anxiety disorder, was cognitively intact but dependent on staff for several activities of daily living. Her care plan did not mention vape or smoking use, despite her being a tobacco user. Multiple staff interviews revealed inconsistent knowledge and practices regarding the storage and use of vape devices. Some staff were unsure if residents could keep vapes in their rooms, and there was confusion about whether smoking assessments applied to vape use. The Director of Nursing and Assistant Director of Nursing both indicated a lack of awareness about the resident's possession of the vape and the associated risks, while the Administrator stated that vapes should not be kept at the bedside and acknowledged responsibility for ensuring compliance. A review of facility policy indicated that residents using e-cigarettes should be assessed for their ability to safely handle the devices, receive instruction on battery safety, and have this documented in their care plan. However, there was no evidence that these steps had been taken for the resident in question. The facility's incident records did not show any vape-related incidents during the review period.