Failure to Assess Smoking Safety and Implement Fall Prevention Measures
Penalty
Summary
Facility staff failed to assess a resident's ability to smoke safely, resulting in a physical injury. The resident, who had severe cognitive impairment, a history of stroke with hemiplegia and aphasia, limited range of motion, and was non-ambulatory, was allowed to smoke in the courtyard without a prior safe smoking evaluation. During this unsupervised activity, the resident set their beard and hair on fire, causing burns to the anterior neck, right chest, and left fingertips. No safe smoking evaluation had been conducted for this resident before the incident occurred. Additionally, the facility failed to implement a fall mat for another resident who was at high risk for falls. This resident had osteoporosis, epilepsy, a left hip fracture, severe cognitive impairment, and required extensive to total assistance with daily activities and mobility. The resident's care plan specifically included the use of a fall mat at the bedside when occupied, but observations on two separate occasions revealed the absence of a fall mat. A nursing assistant incorrectly stated that the resident was independent and did not need a fall mat, and the fall mat was not moved with the resident when they changed rooms. The facility's own policy required the identification and implementation of interventions to prevent avoidable accidents, including the use of assistive devices and supervision based on individual risk assessments. In both cases, the facility did not follow its policy or the residents' care plans, resulting in a failure to provide an environment free from accident hazards and adequate supervision to prevent accidents.