Failure to Ensure Smoking Safety for Resident with Substance Use History
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident with a history of poly substance overuse, specifically regarding smoking safety when under the influence. The resident, who had diagnoses including anxiety, asthma, and respiratory failure, was assessed as having intact cognition and was permitted to smoke independently per the facility's Smoking Program assessments and care plan. However, these assessments did not address the resident's safety when smoking while under the influence of substances. On the night in question, the resident returned to the facility after an outing with family and was observed to be intoxicated, loud, belligerent, and uncooperative. Despite staff interventions, the resident insisted on smoking independently on the patio for several hours, during which time he was in possession of alcohol and exhibited impaired judgment. Staff interviews revealed that the resident was not safe to smoke independently when intoxicated, with reports of him letting cigarettes burn down to his fingers and burning a hole in his jacket, although no injuries were documented. The facility's documentation and care planning did not address the increased risk associated with the resident's substance use and its impact on his ability to smoke safely. Staff recognized the resident's unsafe behaviors when under the influence, but the care plan and smoking assessments failed to include interventions or supervision requirements for these circumstances, resulting in a lack of adequate supervision and failure to mitigate accident hazards related to smoking.