Failure to Accurately Document Resident Tobacco Use in Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected their current tobacco use. Review of the resident's significant change Minimum Data Set (MDS) assessment showed that tobacco use was marked as 'No,' despite the resident actively using smokeless tobacco. The resident's care plan also did not include any focus area regarding tobacco use. During observation, multiple cans of smokeless tobacco were found at the resident's bedside, and the resident confirmed ongoing use since admission. Interviews with nursing staff and the Director of Nursing (DON) revealed they were unaware of the resident's tobacco use, and the DON acknowledged the inaccuracy in the MDS assessment, attributing it to the assessment being completed by an interim corporate RN. The resident in question had a history of hemiplegia and hemiparesis following a stroke, chronic heart failure, schizoaffective disorder bipolar type, and acute respiratory failure with hypoxia. The resident demonstrated moderate cognitive impairment, as indicated by a BIMS score of 9/15. Despite these complex medical needs, the assessment process failed to capture the resident's tobacco use, as required by the Resident Assessment Instrument User's Manual, which specifies that all forms of tobacco use must be documented if used during the 7-day look-back period.