Failure to Prevent Accidents and Ensure Safe Smoking Practices
Penalty
Summary
A deficiency occurred when a resident with a history of falls, impaired cognition, and multiple comorbidities was not transferred according to the physician's order, which required the assistance of two staff members and specific footwear. Instead, a nurse aide attempted the transfer alone, resulting in the resident falling in the bathroom. There was no documentation confirming whether a gait belt or the prescribed footwear was used at the time of the fall. The Director of Nursing Services (DNS) confirmed that the nurse aide did not follow the care plan or physician's order, and the Administrator was unaware of the two-person assist requirement at the time of the incident. Another deficiency was identified regarding the supervision and safety of a resident participating in a supervised smoking program. The facility failed to ensure that smoking materials, including lighters, were properly secured and accounted for. During observation, a staff member left a caddy containing cigarettes unattended in an unlocked area, and the lighter was missing and unaccounted for. Additionally, the resident was observed flicking cigarette ash onto a wet cement patio and wood mulch, rather than using the designated metal ash receptacle, without staff intervention or redirection. Further observations revealed that the fire extinguisher in the smoking area had not been inspected or documented for several months, and there was no evidence of monthly checks or related policies available. The smoking area also contained a wooden planter with multiple discarded cigarette butts, indicating improper disposal of smoking materials. The facility lacked documentation of staff education or in-service training on smoking supervision and safety prior to the survey, and the required quarterly smoking assessments for the resident were not found in the clinical record.