Failure to Include Smoking Status and Safety Interventions in Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and maintain a comprehensive care plan for a resident who was a current smoker. The resident, who had diagnoses including nicotine dependence, emphysema, and congestive heart failure, was assessed multiple times as a smoker and reported to staff that she smoked cigarettes and used oxygen at night only, ensuring she did not wear oxygen while smoking. Despite these assessments and the resident's disclosure, her care plan did not reflect her smoking status or include necessary safety interventions related to smoking, such as ensuring oxygen was removed during smoking. Interviews with nursing staff and review of the electronic medical record confirmed that the resident's smoking status was known to staff and documented in smoking assessments, but this information was not incorporated into the care plan until after the survey process began. The facility's policy required that care plans be used to guide daily care routines, but the omission of the resident's smoking status and related safety measures from the care plan resulted in a lack of comprehensive planning for her care needs.