Failure to Timely and Accurately Assess Residents for Smoking Safety
Penalty
Summary
The facility failed to timely and accurately assess residents for smoking safety, as evidenced by record reviews, interviews, and policy review. Four residents with varying degrees of cognitive impairment and complex medical histories were affected. For two residents with severe cognitive impairment, the smoking safety screens incorrectly indicated no cognitive loss, despite their low BIMS scores and care plans noting significant cognitive deficits. Orders allowed these residents to smoke without supervision, and the assessments did not reflect their true cognitive status. Another resident, also severely cognitively impaired with behavioral issues, had not received a smoking assessment in the previous 12 months, contrary to facility policy. The resident was listed as a supervised smoker, but documentation and assessment practices were inconsistent. Additionally, a cognitively intact resident had not received a smoking safety screen for nearly two years, despite being an active smoker. Staff interviews revealed a lack of adherence to the facility's policy, which required smoking assessments at admission and with each quarterly or comprehensive MDS assessment. Nursing staff acknowledged that assessments were not being completed as required, and there was confusion regarding the use of cognitive assessments. The facility's failure to conduct timely and accurate smoking assessments resulted in residents being permitted to smoke without appropriate supervision or updated evaluations of their safety needs.