Failure to Supervise Residents During Scheduled Smoking Breaks
Penalty
Summary
The facility failed to monitor, supervise, and follow its own policy to ensure a safe smoking environment for two residents who were identified as requiring supervision while smoking. Both residents had care plans specifying the need for staff supervision and assistance during smoking breaks to maintain safety. Despite these documented requirements, on the date of the incident, both residents were left unsupervised on the facility's patio during a scheduled smoke break, which resulted in an altercation between them. Multiple interviews with other residents and staff confirmed that no staff were present on the patio at the time of the incident, and that this lack of supervision had occurred during previous smoke breaks as well. The facility's Smoking Safety Policy and Procedure required that patients in the supervised smoking program receive assistance and monitoring to maintain safety. Scheduled smoke breaks were assigned to specific staff members, but on the day of the incident, the designated staff member was not present due to being called away for another task. Staff interviews acknowledged that supervision was not provided as required, and that both residents involved were not independent smokers and should have been monitored according to their care plans and facility policy.