Failure to Secure Staff Areas and Control Smoking Materials
Penalty
Summary
The facility failed to ensure that staff-only areas remained secure and that smoking materials were properly controlled for one resident. During observations and interviews, a resident demonstrated knowledge of and access to multiple keypad-protected areas, including the conference room, dementia unit, housekeeping closet, shower room, and pantry, where cleaning products were present. The resident also reported knowing the codes for doors leading to the smoking area and exterior exits. Staff confirmed that the resident quickly learned new codes whenever they were changed. The resident was observed possessing lighters and a lock picking kit, and staff present did not intervene or confiscate the smoking materials. The resident also reported vaping in his room despite being told not to and storing smoking materials in his room safe. The resident's care plan required supervision while smoking and specified that smoking materials should be kept by facility staff. However, the resident frequently smoked and vaped unsupervised and maintained possession of smoking materials. Documentation did not reflect incidents of unsupervised smoking, possession of smoking materials, or unauthorized entry into restricted areas, except for a note indicating the resident had attempted to pick locks and was placed on direct supervision. Facility policy required that residents who smoke be supervised and that smoking materials be stored by staff, but these procedures were not consistently followed for this resident, who had diagnoses including schizoaffective disorder, antisocial personality disorder, ADHD, and anxiety disorder.