Failure to Enforce Smoking Policy and Safety Measures
Penalty
Summary
The facility failed to implement and enforce its smoking policy in a safe and consistent manner for all sampled residents who smoke. Observations revealed that one resident, who had no cognitive impairment but suffered from nicotine dependence, lack of coordination, and muscle weakness, was not provided with or wearing a smoking apron/blanket while smoking. The smoking blanket and fire extinguisher were kept in a locked glass case, and the resident did not know how to access them. Staff confirmed that residents were not being offered the protective blanket, despite the resident's care plan requiring its use. Another resident with moderately impaired cognition and a history of tremors and schizophrenia was observed smoking without staff supervision, contrary to the care plan that required supervision. Multiple staff interviews confirmed that residents often smoked without staff present, and there was no designated staff or department responsible for supervising residents during smoking times. Staff acknowledged that the facility's smoking policy was not being strictly enforced, and that supervision was important for resident safety. Additionally, a resident with moderately impaired cognition and COPD was found to be keeping his own cigarettes, despite his care plan and smoking assessment not permitting this. Staff and the infection preventionist confirmed that this practice was a safety risk and not in accordance with the resident's care plan. Furthermore, several residents reported and were observed smoking outside of the facility's established smoking schedule, with staff confirming that the schedule was not being enforced and residents smoked whenever they wanted. The facility's policy required the use of fire-retardant blankets, supervision, and adherence to a smoking schedule, but these measures were not operationalized as required.