Failure to Supervise Resident Smoking According to Assessment and Care Plan
Penalty
Summary
The facility failed to provide required supervision for a resident who smoked, as indicated by the resident's care plan and smoking assessment. The resident, who had a history of hemiplegia and hemiparesis affecting the left side of the body, as well as visual impairment and a history of falls, was assessed as needing supervision while smoking due to poor safety awareness. Despite these documented needs, the resident was allowed to smoke outside the facility premises without staff supervision, as confirmed by interviews with the resident, another resident, and the Activities Director. The facility did not have a designated smoking area or scheduled smoking times, and residents were left to find their own places to smoke outside the facility perimeter. Record review and staff interviews further revealed that the facility lacked a formal smoking program or process for supervising residents who smoke, and the current smoking policy did not address staff supervision for resident smoking safety. The Activities Director and QA nurse both acknowledged that supervision was not consistently provided, and that the facility was still in the process of developing a smoking program. The lack of supervision was contrary to the resident's care plan and assessment, which specifically required supervision to prevent smoking-related injuries.