Failure to Supervise Resident with Unsafe Smoking Behaviors
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent a resident from smoking unsafely in his room, despite a documented history of noncompliance with the facility's smoking policy. The resident, who had a diagnosis of cerebral infarction and required assistance with personal care, transfers, and mobility, was repeatedly found smoking in his room on multiple occasions. His care plan indicated he was not allowed to smoke at the facility except under family supervision and that he was not safe to store or handle his own smoking materials. However, the care sheets used by nursing assistants and nurses lacked any information regarding his smoking plan, restrictions, or required safety checks. Staff interviews confirmed that the care sheets did not provide direction on the resident's smoking status, and some staff were unaware of his restrictions or recent unsafe smoking incidents. Despite the resident's repeated noncompliance and the facility's policy requiring supervision and assessment for residents who smoke, there was no updated smoking assessment after a certain date, and the resident continued to access and use smoking materials unsupervised. Progress notes and staff interviews documented multiple instances where the resident was found actively smoking in his room, with evidence such as ashes and cigarette butts present. The lack of clear communication and documentation regarding the resident's smoking restrictions and supervision requirements contributed to the ongoing unsafe behavior, resulting in a failure to maintain a safe environment free from accident hazards.