Failure to Develop Baseline Care Plan for Smoking Upon Admission
Penalty
Summary
A deficiency was identified when the facility failed to develop a baseline care plan to address the smoking needs of a newly admitted resident within 48 hours of admission. The resident, who had diagnoses including osteomyelitis, severe sepsis, and generalized anxiety disorder, was observed with an open pack of cigarettes at the bedside and reported smoking independently four times a day. Facility staff allowed the resident to keep cigarettes at the bedside, contrary to facility policy, and there was no documentation in the Baseline Care Plan Summary addressing the resident's smoking. Interviews with staff revealed that a safe smoking assessment was initiated but not completed, and the admitting nurse did not develop a baseline care plan for smoking as required. The facility's policy required a safe smoking assessment and the development of care plans based on the assessment and interdisciplinary team findings, as well as the storage of smoking materials at the nurse station. These steps were not followed, resulting in the lack of interventions to promote safe smoking for the resident.