Failure to Enforce Smoking Safety Policy and Prevent Indoor Smoking Near Oxygen Equipment
Penalty
Summary
The facility failed to follow its smoking safety policy and did not ensure that residents refrained from smoking inside shared rooms, including areas where oxygen equipment was in use. Multiple residents, including one who was on continuous oxygen therapy due to respiratory failure, were exposed to cigarette smoke in their shared room. Despite clear facility policies prohibiting smoking inside and near oxygen, staff found a resident with a lit cigarette in a shared room, and cigarette smoke was observed in the air. Other residents in adjacent rooms also reported smelling smoke coming from the hallway and from open windows, indicating that the issue was ongoing and affected several individuals. The resident on oxygen, who had significant medical conditions such as chronic obstructive pulmonary disease, heart failure, and a history of cerebral infarction, reported feeling unsafe and distressed due to being housed with smokers. This resident was not immediately moved after reporting the incident to staff, and only after a subsequent event was the resident relocated to another room. Staff interviews and documentation revealed that the resident who was smoking inside the room admitted to doing so, kept smoking materials in their possession, and had previously been found non-compliant with safe smoking regulations. Staff also observed this resident lighting cigarettes using another resident's lit cigarette during supervised outdoor smoking breaks, in violation of facility policy. Several staff members, including LPNs, CNAs, and social services staff, were aware of the ongoing issue of residents smoking inside the facility but did not consistently follow up or conduct thorough searches for contraband smoking materials. Documentation in the electronic health record was sometimes incomplete or stricken out, and there was a lack of immediate investigation or intervention when allegations of indoor smoking were reported. The facility's own policy clearly prohibits smoking in non-designated areas and near oxygen, but these rules were not effectively enforced, resulting in exposure of non-smoking residents, including those with respiratory conditions, to cigarette smoke.