Failure to Develop and Implement Individualized Smoking Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan addressing the smoking status and preferences of one resident. Despite facility policies requiring the establishment of safe smoking practices and the inclusion of smoking-related privileges, restrictions, and concerns in the care plan, there was no evidence that such a care plan was created for this resident. The resident, who was admitted with quadriplegia and muscle weakness and was cognitively intact, required assistance with activities of daily living and used tobacco. Nursing assessments indicated the need for a smoking apron, one-to-one assistance when smoking, and supervision by staff or family when using nicotine-related devices. However, a review of the resident's comprehensive care plans revealed no documentation of a smoking care plan. Interviews with nursing staff and the DON confirmed that the resident's smoking needs and preferences were not reflected in the care plan, despite staff awareness of the resident's smoking status and required assistance. The facility's failure to document and individualize a care plan for the resident's smoking needs constituted a deficiency in meeting regulatory requirements.