Failure to Provide Individualized Smoking Care Plan and Staff Communication
Penalty
Summary
The facility failed to provide an individualized care plan addressing all the needs of a resident with a history of cerebral infarction who required assistance with personal care, transfers, and mobility. The resident had a documented history of noncompliance with the facility's smoking policy, including incidents of smoking in his room. Although the care plan stated that the resident was not allowed to smoke at the facility and could only smoke outside with family supervision, this information was not included on the care sheets used by nursing assistants and nurses. The care sheets lacked any mention of the resident's smoking plan, restrictions, or required safety checks, and there was no updated smoking assessment after a noted incident. Staff interviews revealed inconsistent awareness and communication regarding the resident's smoking restrictions and safety measures. Some staff were unaware of the resident's recent unsafe smoking practices or the suspension of his smoking privileges, as this information was not documented on care sheets or communicated during shift reports. The facility's policy required care plans to be used in developing daily care routines and to be updated as residents' needs changed, but this was not followed in the resident's case, resulting in a lack of clear, accessible guidance for staff responsible for his care.