Failure to Complete Required Smoking Reassessments After Change in Condition
Penalty
Summary
The facility failed to follow its Safe Smoking policy by not conducting required smoking reassessments for a resident who smoked. According to the facility's policy, residents who smoke must be reassessed annually and after any significant change in condition. Record review showed that the resident, who had a diagnosis including Generalized Anxiety Disorder and a Brief Interview of Mental Status score indicating cognitive response, experienced a significant change in condition. However, no smoking reassessment was performed after this change, and the facility also failed to complete quarterly smoking assessments as outlined in the resident's care plan. Observations confirmed that the resident continued to smoke on the designated patio under staff supervision, with staff controlling access to cigarettes and lighters. Interviews with the resident and the DON confirmed that only two smoking assessments had been completed since admission, and the most recent quarterly assessment was overdue. The care plan specifically required smoking assessments on admission, quarterly, and after significant changes in condition, but these were not completed as required.