Failure to Prevent Vape Pen Use in Presence of Oxygen
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents related to the use of vape pens in the presence of oxygen. One resident with diagnoses including heart disease, chronic obstructive pulmonary disease, and chronic respiratory failure with hypoxia was observed and documented using a vape pen in her room while wearing oxygen. Despite being informed of the facility's smoking policy and signing an acknowledgment, the resident continued to use the vape pen in her room and did not remove her oxygen while vaping. Staff, including RNs, LPNs, and other personnel, were aware of the resident's noncompliance, and it was noted that the resident's husband would bring additional vape pens into the facility. The vape pen was repeatedly found in the resident's possession, and she admitted to using it in her room while on oxygen, in direct violation of facility policy and safety protocols. Another resident with multiple sclerosis and stroke was also found to have a vape pen in her room. This resident admitted to vaping in her room and was aware of the facility's policy but did not consistently return the vape pen to staff after use. Staff observed the vape pen on the resident's overbed table and reported the issue, but the resident was not fully aware of the requirement to return the vape pen to nursing staff. Both residents had care plans indicating noncompliance with the smoking policy and required supervision or interventions to ensure safety, but these interventions were not effectively enforced. Facility policy required that all smoking materials, including electronic smoking devices, be retained and distributed by staff during designated smoking times and that residents not smoke or vape while using oxygen or in areas where oxygen is present. Despite these policies, staff did not consistently enforce the rules, and residents were able to keep vape pens in their rooms and use them unsupervised. Multiple staff interviews confirmed awareness of the residents' noncompliance and the presence of vape pens in resident rooms, but actions taken were insufficient to prevent ongoing violations of the policy.