Failure to Provide Safe Smoking Environment and Supervision
Penalty
Summary
The facility failed to ensure a safe smoking environment for multiple residents by not providing required safety devices, such as smoking aprons, and not maintaining supervision as outlined in residents' care plans and assessments. Observations revealed that several residents who required supervision and the use of smoking aprons while smoking were not provided these aprons during supervised smoking times, despite the aprons being available on the patio. Staff responsible for supervising residents during smoking sessions were unable to identify all residents by name and did not consistently offer or provide the required safety equipment. Additionally, some residents were observed keeping smoking materials, such as cigarettes and lighters, on their person or in their rooms, contrary to facility policy that required these items to be stored in a designated area. Record reviews indicated that the facility did not conduct smoking safety assessments at least quarterly or as needed for several residents, as required by its own policy. For example, some residents had not received updated smoking evaluations for several months, despite changes in their condition or care needs. Care plans for these residents documented the need for supervision and the use of safety devices due to physical or cognitive impairments, but these interventions were not consistently implemented. Residents with diagnoses such as stroke, hemiplegia, cancer, seizure disorder, and cognitive impairment were among those affected by the lack of proper assessment and supervision. Interviews with staff and residents confirmed that the required safety measures were not being followed. Staff members supervising the smoking area were not always aware of which residents required specific interventions, and residents reported not being offered smoking aprons during smoking times. Some residents admitted to keeping smoking materials with them, and staff acknowledged that policy violations were addressed only when observed. These failures resulted in the facility not adhering to its own smoking safety policies and not providing adequate supervision and safety devices to prevent accidents among residents who smoke.