Failure to Supervise Resident Smoking and Enforce Smoking Policies
Penalty
Summary
Facility staff failed to ensure safe smoking practices for one resident who had a history of tobacco use, moderate cognitive impairment, and required partial to moderate assistance with daily activities. The resident's care plan and facility documentation indicated that staff supervision was required during smoking, and that smoking was only permitted in designated areas. Despite these requirements, the resident was observed multiple times smoking unsupervised outside of the designated smoking patio, in areas not visible to staff. During these unsupervised smoking incidents, the resident was able to access and use a lighter kept at his bedside and obtain cigarettes from other residents. Staff interviews confirmed that the resident was not permitted to keep smoking materials and required supervision for safety reasons. Staff members, including a CNA, RN, and activity staff, acknowledged that the resident was not being supervised as required and that the areas where the resident was observed smoking were not approved smoking locations. Record reviews and interviews with the Director of Nursing confirmed that facility policy prohibited unsupervised smoking for residents requiring supervision and restricted smoking to designated areas. The policy also prohibited residents from keeping smoking items in their possession. The failure to follow these policies resulted in the resident smoking unsupervised in unauthorized areas and maintaining access to a lighter, contrary to the care plan and facility procedures.