Failure to Include Smoking Status in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan that included a resident's smoking status. Although the facility's policy requires that care plans address all resident needs with measurable objectives and timetables, one resident was not identified as a smoker in their care plan, despite being listed as an independent smoker requiring supervision on the facility's Smoker List and photo sheet. The resident was observed smoking outside the facility on multiple occasions under staff supervision, and Safe Smoking Evaluations indicated the resident was a safe smoker who required no assistance and that a care plan should be developed. The resident was admitted as a non-smoker but began smoking about a month after admission. However, the care plan dated prior to the update did not reflect the resident's smoking status or related interventions, despite documentation and observations confirming the resident's smoking activity and need for supervision and use of a smoking apron. This omission resulted in the care plan not addressing all of the resident's current needs as required by facility policy.