Failure to Identify, Assess, and Care Plan for Smoking and Elopement Risks
Penalty
Summary
The facility failed to properly identify, assess, and care plan for residents who smoke and those at risk for elopement, as required by facility policy. For two residents, the facility did not timely identify or assess for smoking safety. One resident was not recognized as a smoker during admission, had no completed Smoking Risk Assessment, and lacked a care plan addressing safe smoking, despite being observed smoking in the designated area. Another resident, known by staff to smoke daily and with a diagnosis of nicotine dependence, was not included on the facility's list of current smokers and did not receive required quarterly Smoking Risk Assessments after a certain date. Additionally, the facility failed to reassess a resident after an elopement event and did not develop a comprehensive care plan with interventions to address the risk of elopement. This resident, who was cognitively intact and had a history of non-compliance, was found outside the facility on a motorized scooter without staff knowledge. Although a wanderguard was ordered, the care plan did not include interventions related to the device or address elopement risk, and the resident's information was not included in the elopement binder accessible to staff. Interviews with staff and residents confirmed these deficiencies, with staff acknowledging the lack of timely assessments and care planning. Facility documentation and policy reviews further substantiated that required procedures for identifying, assessing, and care planning for smoking and elopement risks were not followed for the affected residents.