Failure to Supervise Unsafe Smoking Leading to Resident Injuries
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a resident with a history of hemiparesis, epilepsy, and moderately impaired cognition, who was assessed as unsafe to smoke independently. Despite a care plan and smoking evaluation indicating the need for supervised smoking, the resident was repeatedly observed smoking without staff supervision, obtaining cigarettes from other residents and visitors, and searching for discarded cigarettes in designated smoking areas and the parking lot. Staff interviews confirmed that the resident was not safe to smoke independently and that current interventions, which focused on encouraging smoking cessation and education, were ineffective in preventing unsupervised smoking. The resident sustained two separate injuries related to unsupervised smoking: a burn to the inner thigh and a fluid-filled blister, both attributed to dropped cigarettes while smoking alone. Observations and staff interviews revealed that the resident was able to leave the facility unaccompanied and smoke without supervision, contrary to the facility's policy requiring supervision for residents deemed unsafe to smoke independently. The lack of effective supervision and failure to modify interventions placed the resident at increased risk for further smoking-related injuries.