Failure to Update Care Plan with Smoking-Related Safety Intervention
Penalty
Summary
The facility failed to revise the care plan for a resident with schizoaffective disorder and a history of unsafe smoking behaviors, specifically not including a smoking-related safety intervention after the resident sustained burns from using a lit cigarette to remove arm hair. The resident was known to have cognitive impairments affecting judgment and had a documented history of self-inflicted burns related to smoking, with previous assessments identifying him as vulnerable and requiring specific interventions, such as the use of flameless lighters and staff assistance with hair removal. Despite these known risks and a recent incident where the resident burned himself with a cigarette, the care plan was not updated to reflect the newly implemented intervention of one-to-one staff escort and supervision when the resident smoked cigarettes. Multiple staff interviews confirmed that the resident required one-to-one supervision when smoking cigarettes, a measure that was verbally communicated and documented in progress notes and incident reports, but not formally included in the resident's care plan. Staff relied on verbal communication, staff logs, and program sheets to know about the intervention, but the care plan, which is the primary document for guiding resident care, did not reflect this critical safety measure. The omission was acknowledged by several staff members, including the program director, director of nursing, and director of clinical services, who all stated that the intervention should have been included in the care plan for consistency and continuity of care. Facility policies required that residents assessed as vulnerable for unsafe smoking behaviors have a vulnerability care plan with outlined interventions, and that care plans be reviewed and revised as needed. However, the implemented intervention of one-to-one staff escort for cigarette smoking was not documented in the care plan, despite being in practice. This failure to update the care plan meant that the formal documentation did not accurately reflect the resident's current needs and the interventions being provided to ensure his safety.