Failure to Secure Smoking Materials According to Facility Policy
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not following its own policy regarding the storage of smoking materials for two residents who smoked. Observations revealed that both residents were able to retain possession of their lighters and cigarettes, rather than having them secured at the nurses' station as required by facility policy. One resident, who had moderate cognitive impairment due to vascular dementia and depression, was observed with her own lighter and admitted to sometimes forgetting to turn it in to staff. The other resident, who was cognitively intact but had PTSD and depression, also kept his smoking materials with him and stated that staff did not request their return, despite being aware of the policy. Staff interviews confirmed inconsistent enforcement of the smoking materials policy. Multiple staff members, including homemakers, the household coordinator, and the DON, acknowledged that residents' smoking materials were not always checked in and out as required. Staff cited difficulties in tracking lighters, especially when residents purchased new ones during outings, and admitted that some residents routinely kept their smoking materials in their possession. The social worker and household coordinator both expected staff to ensure compliance with the policy, but were unaware that the two residents had their lighters with them. Review of facility documentation, including smoking assessments, care plans, and the smoking policy, showed that both residents had signed smoking agreements and had been instructed on the policy, which clearly stated that all smoking materials were to be stored at the nurses' station and not kept in residents' rooms. The care plans for both residents specifically required staff to secure their smoking materials. Despite these documented requirements, the facility did not consistently implement its policy, resulting in residents retaining access to lighters and cigarettes.