Failure to Implement Fall Precautions and Smoking Supervision
Penalty
Summary
The facility failed to implement and maintain fall precautions as ordered by the physician for a resident with a history of falls. The resident, admitted with diagnoses including cerebral infarction, cognitive impairment, osteoarthritis, and bipolar disorder, experienced multiple falls from bed. Despite a physician's order and care plan intervention for floor mats to be placed on both sides of the bed, observation revealed that only one mat was on the floor while the other was propped against the wall. Staff interviews confirmed the mat was not in place as required, and the Director of Nursing acknowledged the mat should have been on the floor. The facility did not follow the smoking plan of care for a resident assessed as high risk for unsafe smoking practices. The resident was found to have multiple lighters in their room, contrary to the care plan and facility policy, which required smoking materials to be kept at the nurse’s station and not on the resident’s person. Staff interviews provided conflicting information about the policy, but the Nursing Home Administrator ultimately confirmed that lighters should not be kept by residents and validated the concern that the resident was not following the care plan. Additionally, the facility failed to provide required supervision for residents identified as needing assistance while smoking. Two residents, both assessed as requiring supervision and the use of a smoking apron, were observed smoking unsupervised in the designated area, with one resident not wearing the required apron. Both residents also had smoking materials in their possession, despite care plans stating these should be kept at the nurse’s station. Staff interviews confirmed that supervision was not consistently provided, and the Nursing Home Administrator acknowledged the lack of supervision and the presence of smoking materials with residents who required oversight.