Failure to Assess and Supervise Residents for Smoking Safety
Penalty
Summary
The facility failed to assess and supervise residents for smoking safety as required by its own policies, resulting in deficiencies for two of three sampled residents. One resident, admitted with chronic obstructive pulmonary disease and deemed cognitively intact, was listed as an independent smoker but had no documented smoking assessment in the clinical record. This resident was observed disposing of a cigarette improperly and reported never being assessed or observed for smoking safety, despite being provided the facility's smoking policy only recently. Staff confirmed that, per policy, a smoking assessment should have been completed upon admission, but no evidence of such an assessment was found. Another resident, admitted with vascular dementia and care planned for supervised smoking, was found with cigarettes stored in their personal belongings rather than in the medication room as required. This resident was observed entering the smoking area independently, possessing smoking supplies, and smoking without staff supervision, with another resident lighting the cigarette. Staff interviews confirmed that the resident required supervision and that supplies should have been secured by staff, but these procedures were not followed. The lack of supervision and improper storage of smoking materials were acknowledged by facility staff.