Failure to Enforce Smoking Safety Policies and Supervision
Penalty
Summary
The facility failed to follow its own smoking safety policies and procedures for residents who smoke, resulting in multiple deficiencies. Several residents, including one who is blind and at high risk for falls and injury, were observed smoking unsupervised in unauthorized areas, such as immediately outside the activity room door and on the sidewalk, rather than in the designated smoking area. Staff interviews confirmed that residents regularly smoked in these locations, especially during inclement weather, and that staff were aware of the violations but did not consistently intervene or enforce the rules. Cigarette butts were observed littering the ground around these unauthorized smoking areas, indicating ongoing noncompliance. Residents who smoked were not consistently assessed or monitored according to facility policy. One resident, who was blind and had a history of unsafe smoking behavior and prior property damage, was allowed to keep smoking materials in his possession and was not required to sign out when leaving to smoke. His care plan indicated he was unsafe to smoke independently, yet he continued to do so without supervision. Another resident, who required a smoking apron for safety, was not documented as a smoker in his care plan and was observed smoking without the required apron. A third resident reported never being assessed for safe smoking practices and was also observed keeping smoking materials in his room and smoking in unauthorized areas. Staff interviews revealed a lack of consistent enforcement of smoking policies, with some staff deferring responsibility to others or citing resident noncompliance and belligerence as barriers to enforcement. The facility's written policy stated that no accommodations for smoking or tobacco products would be made and that such products were not permitted on the premises, yet this policy was not followed in practice. These failures occurred across multiple shifts and days, involving several staff members and placing residents and others at risk of exposure to second-hand smoke, fire, and injury.