Unsafe Resident Environments Due to Space Heaters and Inadequate Smoking Supervision
Penalty
Summary
Facility staff failed to ensure that resident environments were free from accident hazards and did not provide adequate supervision to prevent accidents. Multiple deficiencies were identified, including the presence of portable space heaters in resident rooms and inadequate supervision and unsafe smoking practices among residents identified as smokers. Four portable space heaters were observed in use in the rooms of non-ambulatory residents, despite a facility policy prohibiting such appliances in resident care areas. Staff interviews revealed a lack of awareness regarding the prohibition of space heaters, and the heaters were found plugged in and operating near residents' beds. In addition to the space heater issue, the facility did not adequately supervise or implement safe smoking practices for several residents with significant medical conditions, such as chronic respiratory failure, muscle weakness, paraplegia, and cognitive impairments. Some residents were found to possess cigarettes and lighters, and were smoking outside the building without staff supervision or proper safety equipment, such as smoking aprons. There was a lack of individualized care plans addressing smoking for these residents, and staff were often unaware of which residents smoked or the facility's smoking policy. In some cases, residents with impaired mobility or cognitive status were allowed to keep smoking materials on their person or in their rooms, and staff did not monitor for behaviors such as receiving cigarettes from other residents. Observations and interviews indicated that staff did not consistently provide or document education on the smoking policy to residents or staff, and there was confusion among staff regarding the facility's status as a non-smoking facility. Some residents reported not being informed about the smoking policy or not receiving required adaptive equipment for safe smoking. The lack of supervision and failure to implement safety measures for both space heaters and smoking practices resulted in the identification of Immediate Jeopardy situations by surveyors.