Failure to Provide Adequate Supervision and Safe Smoking Practices
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and multiple medical diagnoses, including sepsis, blood clots, tremor, and alcohol dependence, was not provided adequate supervision to prevent accidents while smoking. The resident was observed independently leaving the facility in a wheelchair, wearing only gripper socks, and crossing a street to smoke. During this time, the resident navigated around moving vehicles, smoked in the street, and disposed of cigarette butts by putting them out with his fingers and placing the remnants in his jacket pocket. The resident reported that he was not given guidance on safe smoking practices and that staff had previously accompanied him to the same location, which was not considered safe by facility staff. The facility's smoking policy prohibits smoking on the property and requires residents to go off-premises to smoke, with specific procedures for signing out and returning smoking materials to staff. However, the resident did not consistently return smoking materials, sometimes keeping cigarettes and a lighter in his room. Staff interviews revealed a lack of training on smoking assessments and unclear procedures for monitoring and retrieving smoking materials. The social worker who completed the resident's smoking assessment had never done one before and had not received training. The assessment did not address all relevant safety concerns, such as the resident's ability to safely navigate the environment or dispose of cigarette materials. Further, there was no designated receptacle for cigarette disposal, and staff were uncertain about proper procedures for safe smoking off-premises. The resident's actions, including smoking in the street, improper disposal of cigarette butts, and failure to return smoking materials, were not adequately supervised or addressed by staff. Facility leadership acknowledged that the observed behaviors were unsafe and not in line with policy, but there was no evidence of consistent staff training or clear protocols to ensure resident safety during smoking activities.