Failure to Prevent Resident Access to Cigarettes in Violation of Smoking Policy
Penalty
Summary
The facility failed to ensure a resident received adequate supervision to prevent accidents and did not maintain an environment free from accident hazards. A male resident with moderate cognitive impairment, as indicated by a BIMS score of 11, and diagnoses including Type 2 Diabetes Mellitus, hypertension, alcohol abuse, and gait abnormalities, was found with a box of cigarettes at his bedside. Facility policy prohibits residents without independent smoking privileges from keeping smoking items in their rooms, requiring such items to be stored securely by staff. Despite this, the resident was able to obtain and keep cigarettes in his room without staff knowledge. Multiple staff interviews confirmed that cigarettes are supposed to be kept locked at the nurses' station or in medication carts, and that residents are not allowed to have them in their rooms. The resident admitted to bringing the cigarettes in his jacket and not informing staff. Staff members, including a CNA and an LVN, reported not seeing the cigarettes during their rounds earlier that day. The DON and Administrator both acknowledged the policy and were unsure how the resident was able to keep cigarettes in his room, noting that the resident may have brought them in after being out on pass.