Failure to Supervise and Monitor Safe Smoking and Vaping Practices
Penalty
Summary
A deficiency occurred when the facility failed to implement a system to ensure residents were properly supervised and monitored for safe smoking and the use of electronic vaping devices. One resident, who was a known user of vaping devices and required continuous oxygen therapy due to COPD and other medical conditions, was not identified on the facility's smoking or vaping user list. The resident's care plan did not address the use of vaping devices, nor did it provide interventions or supervision related to vaping or smoking in the resident's room. Staff were aware that the resident vaped in their room and charged the devices for them, but there was no documentation or care plan intervention addressing this behavior. The resident was observed with multiple vaping devices and chewing tobacco in their room, along with an oxygen concentrator. Despite the facility's policy prohibiting smoking and vaping in non-designated areas and specifically warning against the use of such devices around flammable gases like oxygen, the resident continued to vape in their room. Staff interviews confirmed that the resident was known to vape in their room while on oxygen, and that staff routinely charged the vaping devices for the resident. The resident was not listed as a smoker or vape user on the facility's records, and their care plan only addressed tobacco chewing, not vaping or smoking. The deficiency resulted in a serious incident where the resident, while using oxygen in their room, lit a cigarette, causing a flash burn to their face and nose. The incident report and hospital records confirmed partial thickness burns to the resident's face, requiring emergency evaluation and treatment. Staff and administrative interviews revealed a lack of awareness and oversight regarding the resident's vaping and smoking behaviors, as well as a failure to update care plans and assessments to reflect the resident's actual practices.