Failure to Honor Resident Smoking Break Requests and Address Council Concerns
Penalty
Summary
The facility failed to honor a resident's request for a supervised smoking break and did not timely address or resolve requests for an additional smoke break for two other residents. One resident, who had diagnoses including neuromuscular dysfunction of the bladder, depression, and nicotine dependence, required staff supervision for smoking and assistance with transfers. This resident reported not receiving a requested smoke break after asking the Social Services staff, who communicated the request to management but did not ensure follow-through. The administrator was aware of the request but was occupied with another situation and assumed the need had been addressed. Additionally, two other residents, both cognitively intact and dependent on staff for transfers, had participated in resident council meetings where a request for an additional smoking break between the existing scheduled times was made. Despite repeated documentation of this request in council meetings, there was no evidence that the facility addressed or resolved the concern in subsequent meetings or in practice. The designated smoking times did not include a break between 4:00 P.M. and 9:00 P.M., as requested by the residents. Staff interviews confirmed that the facility was unable to provide the additional supervised smoking break due to staffing limitations, even though the responsibility for supervising smoking was shared among staff. The Activities Director indicated that a new staff member would be trained to assist with smoking supervision, but at the time of the survey, the additional break had not been implemented. Facility policies reviewed stated that residents have the right to a dignified existence and self-determination, but the facility did not ensure these rights were upheld regarding the residents' smoking requests.
Plan Of Correction
Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 7/30/25 as the facility's allegation of compliance date. F550 The facility failed to maintain the rights of residents by not providing extra smoke breaks to residents #24, #29, #35 when requested. Step 1: The facility immediately reviewed smoking policy and current smoking schedule, additional smoke added with adjustments of current times. Completed on 6/24/25. Step 2: To identify other residents that have the potential to be affected, IDT reviewed current in-house residents that smoke. Completed on 6/24/25. Step 3: To prevent this from recurring, the facility IDT will complete updated smoking assessments on current residents choosing to smoke, will have a meeting with the smokers to review the policy, updated smoking times, and have noted residents sign updated smoking contracts. Completed on 7/10/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will interview 3 smokers per week x4 weeks then monthly x2 months to ensure policy/smoking break compliance and verify new times are working as desired for residents. Audits will begin 7/14/25.