Failure to Prevent Smoking and Elopement Hazards
Penalty
Summary
A deficiency occurred when a resident with a history of chronic obstructive pulmonary disease, nicotine dependence, and cognitive communication deficit was observed smoking a cigarette in the facility courtyard, despite the facility's policy prohibiting smoking and possession of smoking materials on the premises. The resident had a BIMS score indicating intact cognitive function and was on a nicotine patch, but staff were unaware she was actively smoking. The resident admitted to smoking since admission, keeping cigarettes, a lighter, and a vape in her personal bag, and stated that other residents also smoked without detection. Multiple staff members, including nursing and social work, were unaware of her smoking status or possession of smoking materials, and the facility's policy requiring all smoking materials to be surrendered was not enforced. Another deficiency involved a resident with muscle wasting, atrophy, and an abdominal aortic aneurysm, who required partial to moderate assistance for mobility and was at risk for falls. The resident left the facility without signing out or completing the required leave of absence documentation. Staff did not confirm the resident's whereabouts for several hours, and when the resident was found missing, the response did not follow the facility's elopement policy, which required immediate notification, a prompt search, and contacting authorities if the resident was not located. The resident's ability to make healthcare decisions was not documented, and the required risk assessments and sign-out procedures were not completed. In both cases, the facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents. Staff were not consistently aware of residents' behaviors or risks, and policies regarding smoking and elopement were not effectively implemented or followed, resulting in deficiencies related to resident safety and supervision.