Failure to Prevent Accident Hazards: Unsafe Smoking and Elopement
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for two residents, resulting in deficiencies related to unsafe smoking practices and inadequate elopement prevention. One resident, who was cognitively intact and had a history of noncompliance with smoking policies, repeatedly smoked cigarettes in their room despite the facility's policy requiring smoking only in designated areas. The resident's care plan was not updated in response to multiple documented violations, and staff failed to revise the smoking assessment or implement additional safety interventions after incidents, including one where a hot cigarette butt singed trash in a shared bathroom. The resident's medical record also indicated a history of disruptive behavior and previous fire-related incidents in another facility, yet the facility did not adjust the care plan or restrict access to smoking materials accordingly. Another resident, with moderate cognitive impairment and a history of exit-seeking behavior, was not adequately supervised to prevent elopement. The resident's care plan required the use of a WanderGuard device and securing the window to prevent unsupervised exits. However, staff failed to ensure the WanderGuard was consistently in place and functioning, and the window in the resident's room was found to open fully, contrary to care plan instructions. The resident was observed without a WanderGuard on multiple occasions and was able to exit the building unsupervised through an emergency exit. Staff interviews revealed that the resident frequently removed the WanderGuard, and incidents of elopement were not documented or reported to administration as required. The facility's inaction in revising care plans, conducting new assessments, and ensuring the implementation of safety interventions for both residents led to a finding of immediate jeopardy. The lack of supervision and failure to enforce policies regarding smoking and elopement prevention created a situation where residents, including those with physical and cognitive limitations, were exposed to significant safety risks. Documentation and communication lapses further contributed to the ongoing deficiencies.
Removal Plan
- Remove smoking materials from R19's room and store them in a locked area.
- Reeducate R19 and have R19 sign the facility's smoking policy and behavior contract for smoking.
- Place R19 on checks to ensure smoking materials are not found in R19's room.
- Revise R19's care plan to reflect R19's current smoking plan.
- Update the facility's smoking policy to include information on where smoking materials will be kept to maintain safety and reduce the risk of unsafe smoking.
- Educate residents who smoke on the facility's smoking policy, review the designated smoking area, and collect all smoking materials for safe storage.
- Educate staff on the facility's smoking policy and procedure.
- Initiate audits to ensure all smoking materials remain locked and the smoking policy is being followed.
- Place a WanderGuard on R27 and review R27's order to ensure staff check placement, location, and function.
- Place R27 on checks to monitor R27's location and ensure safety.
- Secure the window in R27's room.
- Revise R27's care plan with updated interventions.
- Review residents at risk for elopement to ensure interventions are appropriate and in place.
- Educate staff on the facility's elopement policy and the importance of monitoring for exit seeking behavior.
- Educate staff on the importance of checking for WanderGuard placement and function.
- Review the facility's elopement policy to ensure information is included regarding what to do when a resident removes a WanderGuard.
- Initiate audits to ensure WanderGuards are in place and functioning properly.