Failure to Develop and Implement Smoking Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plan interventions for two residents with nicotine dependence who were observed smoking independently. Both residents had documented diagnoses including hypertension and nicotine dependence, and their most recent smoking assessments were completed. However, review of their care plans revealed no goals or interventions addressing their smoking behaviors. Despite being cognitively intact, one resident required limited assistance with activities of daily living (ADL), while the other required extensive assistance. Both residents reported smoking since admission or shortly thereafter. Interviews with the MDS Coordinators, Director of Nursing (DON), and Administrator confirmed that they were unaware these residents had not been care planned for smoking. The staff acknowledged that all residents who smoke are expected to have care plans with specific goals and interventions, but this was not done for the two residents in question. The deficiency was identified through record review, observation, and staff interviews.