Failure to Implement Care Plans for Smoking Safety and Fall Prevention
Penalty
Summary
The facility failed to implement the care plans for two residents as observed and documented by surveyors. One resident, with diagnoses including heart disease, COPD, diabetes, and moderate intellectual disabilities, was care planned to wear a smoking apron and be supervised while smoking. Despite this, the resident was observed on multiple occasions in the designated smoking area holding a lit cigarette without wearing the required smoking apron, even though staff were present and aware of the care plan requirements. Another resident, with a history of traumatic brain injury, reduced mobility, and moderate cognitive impairment, was care planned to have a fall mat placed at the bedside due to previous falls. However, repeated observations showed that the fall mat was propped against the wall away from the bed and not in use as intended. Staff interviews confirmed that the fall mat was not in place according to the care plan, and the care plan had not been individualized to the resident's needs.