Failure to Follow Smoking Assessment and Policy for Resident
Penalty
Summary
The facility failed to follow its established smoking policy in the assessment and management of one resident's smoking status. According to the facility's policy, residents who smoke are to be reviewed for safety upon admission, with licensed staff responsible for completing a smoking review, and all smokers capable of understanding the rules are to sign a smoking agreement. The policy also requires that smokers be reviewed on admission, quarterly, and as needed based on changes in condition. However, for one resident, the admission record and Minimum Data Set indicated no current tobacco use, and there were no physician orders related to smoking. The resident's smoking evaluation was completed incorrectly, failing to reflect the resident's actual smoking status. Despite documentation indicating the resident was not a smoker, the care plan identified the resident as at risk for side effects from smoking and recommended the use of a smoking apron. The resident reported smoking multiple times daily, which was confirmed during an interview. Facility leadership, including the Assistant Director of Nursing and the Director of Nursing, acknowledged that the required physician order and accurate smoking evaluation were not completed, resulting in noncompliance with the facility's smoking policy and regulatory requirements.