Failure to Develop Comprehensive Care Plan for Resident with Smoking/Vaping History
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan addressing a resident's history of smoking and vaping, despite multiple documented instances and assessments indicating the resident's tobacco and vape use. Upon admission, the resident was found with two vape devices, which were removed and stored by staff, but no subsequent smoking assessment or care plan interventions were documented. The resident's medical records, including hospital discharge summaries and nursing notes, consistently referenced a significant history of tobacco and vape use, yet these issues were not incorporated into the resident's care plan from admission through subsequent hospitalizations and readmissions. Further review revealed that the facility had a policy requiring the interdisciplinary team to address all identified resident needs, including those found in admission and discharge summaries, but the care plan for this resident did not reflect their smoking or vaping history. Interviews with facility leadership confirmed that the care plan should have included this information. Additionally, the resident was not listed among those grandfathered in for smoking privileges after the facility became non-smoking, despite clear evidence of ongoing tobacco and vape use.