Failure to Assess and Supervise Resident Smoking Leads to Injury and Immediate Jeopardy
Penalty
Summary
Facility staff failed to ensure that residents identified as smokers were properly assessed for their capability and safety needs regarding smoking. Several residents, including those with significant medical histories such as schizoaffective disorder, COPD, asthma, and muscle weakness, were not adequately evaluated for safe smoking practices. In one case, a resident with a history of non-compliance and moderate cognitive impairment was not given a complete safe smoking assessment upon admission, despite documentation indicating the facility was aware of his smoking behavior and non-compliance with safety protocols. Staff did not provide adequate monitoring and supervision of residents who smoked, allowing them to access lighters, cigarettes, and electronic cigarettes unsupervised. Multiple residents were observed smoking without staff supervision, not using required safety equipment such as smoking aprons or cigarette holders, and possessing smoking materials in their personal belongings. In one incident, a resident smoked while using oxygen, resulting in burns to his face and hand, and was later observed smoking unsupervised again after returning from the emergency department. Staff interviews confirmed that unsupervised smoking was a known and ongoing practice, and that residents often disregarded facility smoking policies. Facility documentation and staff interviews revealed that smoking paraphernalia was not consistently secured, and safety precautions such as fire blankets were not available in designated smoking areas. Residents and staff reported that the enforcement of smoking policies had become lax, with residents allowed to keep their own lighters and cigarettes and smoke at will. The lack of supervision and failure to implement and enforce safety measures led to multiple instances of unsupervised smoking, non-compliance with safety protocols, and a serious injury to a resident.