Failure to Develop Smoking Care Plan for Resident with Smoking History
Penalty
Summary
The facility failed to develop a care plan addressing smoking for a resident with a history of chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease, and nicotine dependence. The resident was admitted on 03/13/25 and had documented smoking assessments indicating both the need for supervision and, at another time, no need for supervision or adaptive equipment. Despite these assessments and the resident's long-term smoking history, the care plan did not include any interventions or considerations related to smoking. Interviews confirmed that the resident smoked at the facility and that the MDS nurse was unaware of the resident's smoking status when completing the assessment, resulting in the omission of a smoking care plan. Facility policy required that smoking privileges, restrictions, and concerns be documented in the care plan and communicated to all staff, which was not done in this case.