Failure to Complete Smoking Assessment for Resident
Penalty
Summary
The facility failed to complete a smoking assessment for a resident who was reviewed for smoking. Upon admission, the resident was documented as not being a smoker and was assessed as severely cognitively impaired, with no tobacco use coded in the Minimum Data Set (MDS) assessment. The resident's care plan did not include any interventions or considerations related to smoking, and there was no evidence in the medical record that a safe smoking assessment had been conducted. Despite this, the resident was later observed smoking independently in the facility's designated smoking area without staff supervision. Interviews with the responsible party and staff revealed that the resident began smoking again several weeks after admission, but no updated assessment or care plan was created to address this change. Facility staff, including the nurse, unit manager, DON, and administrator, confirmed that a smoking assessment should have been completed when the resident resumed smoking, but this was not done.