Failure to Prevent and Address Unauthorized Smoking and Substance Use
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents with a history of tobacco and substance use. One resident, with hemiplegia, hemiparesis, and depression, was repeatedly observed by staff vaping in their room and bathroom, in violation of the facility's smoking policy. Despite these observations, there was a lack of consistent reporting to management, and the Director of Nursing Services (DNS) was not made aware of the incidents. The care plan for this resident did not initially address the ongoing unauthorized use of smoking materials, and staff interviews revealed that management was aware of the behavior but did not take effective action. Another resident, with diagnoses including alcohol dependence, repeated falls, and anxiety disorder, was involved in multiple incidents of smoking and possession of smoking paraphernalia within the facility. Documentation showed that this resident was found with marijuana, a lighter, and a smoking pipe on several occasions, and was observed smoking in both their room and a facility bathroom. The facility failed to notify the resident's physician or conservator after these incidents, did not revise the care plan to address the repeated policy violations, and did not consistently document or implement increased supervision or other interventions. Staff interviews indicated that the issue of residents smoking, including marijuana use, was ongoing and that reporting and follow-up were inconsistent or lacking. Facility policy required smoking assessments upon admission and after significant changes, as well as care plan updates and supervision for residents with smoking risks. However, the facility did not adhere to these requirements, as evidenced by the lack of smoking assessments, care plan revisions, and documentation of interventions following repeated incidents. The facility also failed to consistently notify responsible parties and medical providers, and did not maintain adequate records of investigations or actions taken in response to the observed hazards, resulting in a failure to protect residents from accident hazards related to unauthorized smoking and substance use.