Failure to Supervise Resident During Smoking Results in Fall
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent accidents during smoking for one resident. The resident, who had a history of alcohol abuse, unspecified dementia, alcoholic cirrhosis, bipolar disorder, COPD, prostate cancer with urinary catheter, partial foot amputation, and difficulty ambulating, was observed lying in the street after falling from his wheelchair while unsupervised outside the facility to smoke. The resident was found with cigarettes and a lighter in his possession and stated that he keeps his own cigarettes in his room and smokes outside whenever he wants, without supervision or use of the facility's designated smoking area or safety equipment. Review of the resident's medical record and facility documentation revealed that the resident had moderate cognitive impairment (BIMS score of 8) and was assessed as requiring supervision while smoking, with adaptive equipment such as a smoking apron recommended. Despite this, the resident was not supervised during smoking sessions, and staff confirmed that supervision had not been provided as required by the facility's policy. The facility's smoking policy also prohibits residents from keeping smoking items except under direct supervision, which was not followed in this case.