Failure to Address Tobacco Use in Resident Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan addressing tobacco use for a resident who was cognitively intact and used smokeless (chewing) tobacco daily. Despite the facility's policy requiring comprehensive assessments and care plans that include all resident needs, preferences, and treatments, the resident's ongoing use of smokeless tobacco was not incorporated into their care plan. Medical record reviews confirmed the resident's tobacco use, and observations over several days showed the resident keeping and using smokeless tobacco in their room. Interviews with staff, including an LPN and the DON, confirmed that the resident's tobacco use was known and that such information should be included in the care plan. However, the care plan had not been updated to reflect this aspect of the resident's care, despite clear evidence from assessments, observations, and staff interviews that the resident regularly used smokeless tobacco.