Failure to Assess Resident for Smoking Safety
Penalty
Summary
The facility failed to assess a resident for safety while smoking, as required by their own policy. Clinical record review showed that the resident, who had intact cognition and multiple diagnoses including hypertension, peripheral vascular disease, renal failure, respiratory failure, and an above-the-knee amputation, used tobacco products. Despite this, there was no documentation of a smoking assessment in the resident's electronic health record, nor was smoking addressed in the resident's care plan. Progress notes indicated that the resident requested cigarettes and a lighter for an appointment, and staff reviewed the smoking policy with the resident, but no formal assessment was completed. Observation revealed that staff provided cigarettes and a lighter to the resident and assisted with lighting and disposing of cigarettes during a smoking period. Interviews with the DON and Administrator confirmed that a smoking assessment should have been completed and included in the care plan, in accordance with facility policy, which requires evaluation of smoking status on admission and routine re-evaluation of the ability to smoke safely. The lack of assessment and care planning for smoking safety constituted the deficiency.