Inadequate Supervision During Smoking Breaks Led to Marijuana Use
Penalty
Summary
The facility failed to provide adequate supervision during scheduled smoking breaks, which resulted in two residents being able to smoke marijuana in the designated smoking area. According to staff interviews and camera footage, one resident lit a marijuana joint from his cigarette and passed it to another resident, who also smoked it. Both residents were deemed not safe to smoke unsupervised according to their Safe Smoking Evaluations, and staff were present but positioned in a way that did not allow them to fully observe the residents' actions. The staff noticed the smell of marijuana and observed the exchange, but only after the residents had already smoked the substance. Both residents involved were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores, and had medical histories including cerebral infarction and hemiplegia/hemiparesis for one of the residents. The facility's policy required supervision for residents during smoking, but the staff's positioning in the smoking area allowed for blind spots, particularly with one resident facing away from staff and cameras. This lack of adequate supervision directly led to the incident where marijuana was smoked and shared between residents.