Failure to Implement Smoking Policy and Ensure Resident Safety
Penalty
Summary
The facility failed to implement its established smoking policy to ensure resident safety and regulatory compliance. Observations revealed that the smoking policy was not posted in a conspicuous and legible manner in the designated smoking area or elsewhere in the facility, as required by the facility's own policy. Additionally, the designated smoking patio lacked necessary fire safety equipment, such as a fire extinguisher or fire blanket, and there was no signage indicating it was a designated smoking area. The only available fire extinguisher was kept inside a locked cabinet within the facility, not accessible in the smoking area where residents regularly smoked. Further review showed that the facility did not conduct required assessments for safe smoking practices for all residents who smoke. Specifically, one cognitively intact resident with a diagnosis of Wernicke's encephalopathy and nicotine dependence was not assessed for safe smoking, despite documented incidents where the resident attempted to light a cigarette using a lighter taken from a staff member and became agitated and verbally aggressive when denied access to the smoking patio. Documentation indicated that the resident was told he could not participate in smoking until assessed by nursing, but this assessment was not completed. Interviews with the DON and NHA confirmed that the facility did not follow its own smoking policy regarding resident assessment, posting of the policy, and provision of fire safety equipment in the designated smoking area. These failures were observed during the survey and corroborated by staff interviews and clinical record reviews.