Failure to Complete Smoking Assessments and Care Plans for Residents Who Smoke
Penalty
Summary
The facility failed to ensure that three residents who smoked had complete and accurate smoking assessments, and did not provide a care plan related to smoking for one of these residents. Specifically, one resident with moderate cognitive impairment and a history of tobacco use was observed smoking in the designated area but had no smoking assessment or care plan addressing smoking. Another resident with severe cognitive impairment and nicotine dependence was identified as a smoker, but their smoking assessment was incomplete and marked as in process. The third resident, also with severe cognitive impairment and a history of tobacco use, had a care plan indicating the need for supervised smoke breaks, but the quarterly assessment inaccurately documented their smoking status, despite observations of the resident smoking in the designated area. The facility's policy required that residents who smoke be assessed upon admission, re-admission, with significant change, and at least quarterly thereafter, with care plans developed based on these assessments. However, record reviews, staff interviews, and direct observations revealed that these procedures were not consistently followed. The Director of Health Services confirmed the lack of completed or accurate smoking assessments and care plan interventions for the affected residents, acknowledging that this failure could result in staff not knowing what to monitor regarding residents' smoking behaviors.