Failure to Provide Required Smoking Safety Equipment
Penalty
Summary
During a facility tour, an employee was observed smoking on the property outside of a designated smoking area. The area where the employee was smoking did not have ashtrays made of noncombustible material and safe design, nor were there metal containers with self-closing cover devices available for ashtray disposal, as required by NFPA 101 and NFPA 1 standards. These observations were confirmed in real time with the Facility Manager. At the exit conference, the administrator stated that the facility has a smoking regulations policy that prohibits smoking anywhere on the property at any time. Despite this policy, the observed smoking incident occurred, and the required smoking safety equipment was not present in the area where the violation took place. No information about residents or their medical conditions was included in the report.
Plan Of Correction
The Staff member was identified and was immediately educated on the facility's non-smoking policy. The nursing home administrator conducted walking rounds of the outdoor areas surrounding the facility as it relates to any concerns with facility adherence to non-smoking policy. No concerns were identified. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator/Designee re-educated facility staff on the non-smoking policy. The Nursing Home Administrator/Designee will conduct a random audit weekly 3 times a week on the facility staff's adherence to the facility's non-smoking policy by visual inspection. These audits will be conducted weekly for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The Staff member was identified and was immediately educated on the facility's non-smoking policy. The nursing home administrator conducted walking rounds of the outdoor areas surrounding the facility as it relates to any concerns with facility adherence to non-smoking policy. No concerns were identified. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator/Designee re-educated facility staff on the non-smoking policy. The Nursing Home Administrator/Designee will conduct a random audit weekly 3 times a week on the facility staff's adherence to the facility's non-smoking policy by visual inspection. These audits will be conducted weekly for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring. The corridor door equipped with a self-closing mechanism leading to the clean utility room by the nurse's station was called for servicing and repairs. No residents were found to be affected by this alleged deficient practice. The Nursing Home Administrator educated the Maintenance staff on maintaining fire doors in working condition, including latching and closing appropriately. The Nursing Home Administrator/Designee will conduct weekly audits on 3 fire doors to ensure they are latching and closing appropriately for 3 months. The findings of these audits will be reported in the next risk management/Quality assurance committee meeting until the committee determines substantial compliance has been met and recommends quarterly monitoring.