Failure to Supervise Smoking and Safely Store Smoking Materials
Penalty
Summary
The facility failed to ensure that a resident who required supervision while smoking was adequately monitored, resulting in a burn injury. On a windy day, the resident was outside in the designated smoking area, but was not in the direct line of sight of the assigned hospitality aide. While attempting to light a cigarette, ashes blew into the resident's hair, igniting it and causing a burn to the left ear. The hospitality aide did not immediately report the incident to nursing staff, as requested by the resident, which led to a delay in the assessment and treatment of the burn. The incident was only reported two days later when the resident experienced pain and a blister was noticed by another staff member. Additionally, the facility failed to ensure that electronic smoking materials were safely stored and not used inside the facility. Another resident was observed with an e-cigarette in bed and on the bedside table, and admitted to using the device in the room. Multiple staff members confirmed that residents kept and used e-cigarettes in their rooms, despite facility policy prohibiting the storage and use of smoking materials, including e-cigarettes, inside the facility. There was no documentation in the resident's care plan or smoking assessment regarding the use or storage of e-cigarettes, and staff were not consistently aware of or enforcing the policy. Both deficiencies were identified through observation, interviews, and record review. The facility's policies required supervision during smoking, secure storage of all smoking materials, and immediate reporting of incidents. However, these protocols were not followed, resulting in a resident sustaining a burn injury without prompt medical attention and another resident having unsupervised access to and use of an e-cigarette in their room.