Failure to Complete Safe Smoking Assessment and Prevent Access to Smoking Materials for Cognitively Impaired Resident on Oxygen
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not completing a required quarterly Safe Smoking Assessment for a resident with severe cognitive impairment and on oxygen therapy. The facility's smoking policy mandates that all smokers, including those using e-cigarettes, be assessed for safe smoking practices on admission, quarterly, with significant changes, and as needed. However, review of the resident's medical record revealed that the quarterly Safe Smoking Assessment was not completed at the time of the resident's Minimum Data Set (MDS) assessment. The resident had a BIMS score indicating severe cognitive impairment and was receiving oxygen therapy, both of which are significant risk factors for unsafe smoking. Observations showed the resident asleep in bed with oxygen infusing and a pack of cigarettes and a lighter on the over bed table, contrary to facility policy and staff expectations. Staff interviews confirmed that the resident was considered an unsafe smoker due to recent decline and should not have had access to smoking materials, especially while on oxygen. The MDS Coordinator acknowledged the assessment was missed and that residents with severe cognitive impairment require supervision for smoking. The resident's responsible party also reported instructing staff not to store smoking materials in the resident's room due to dementia.