Failure to Complete Smoking Risk Assessment for Resident
Penalty
Summary
The facility failed to complete a smoking risk assessment for a resident who was admitted with multiple diagnoses, including encephalopathy, type 2 diabetes, hypertension, and heart failure, and who required assistance with personal care. Upon admission, the resident's care plan identified a risk for injury due to smoking and included an intervention to re-evaluate smoking privileges per facility policy. However, the initial nursing risk assessment indicated that a smoking safety evaluation was not completed because the resident was believed not to smoke, and no further smoking safety evaluations were conducted after admission. Subsequent documentation showed that the resident had a past interest in smoking, and direct observation revealed the resident smoking on the facility's patio with assistance from activity staff, but without a protective smoking apron. Interviews with nursing staff and the DON confirmed that a smoking risk assessment should have been performed when it became known that the resident smoked, in accordance with facility policy, which requires such assessments on admission, quarterly, and as needed. The lack of an updated smoking risk assessment potentially placed the resident's safety at risk.