Failure to Supervise and Safeguard Residents During Smoking Activities
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for four residents who smoked, resulting in a finding of Immediate Jeopardy. Surveyors observed multiple instances where residents were not properly assessed for their ability to smoke safely, and care plan interventions were either missing or not implemented. Residents were seen retrieving and smoking discarded cigarette butts from receptacles, accumulating cigarette ashes and burn holes on their clothing, and using unsafe, non-fire-rated containers for cigarette disposal. Staff interviews revealed a lack of consistent monitoring and supervision in the designated smoking areas, with some staff unaware of the need for supervision or the presence of safety equipment such as smoking aprons. One resident with moderate cognitive impairment and a history of psychiatric and neurological diagnoses was observed with cigarette ashes on his clothing, taking cigarette butts from receptacles, and attempting to light and share them with others. Another resident, cognitively intact but with significant medical conditions including COPD and atrial fibrillation, was seen using a wooden clothespin to hold cigarettes and a plastic car ashtray, which is not fire-rated, for disposal. A third resident, also cognitively intact but with hemiplegia and visual impairment, was observed with burn holes in her shirt and reported difficulty using a lighter due to her physical limitations. Her care plan indicated the use of a smoking apron, but it was not available during the initial survey observations. A fourth resident, with a history of dementia and developmental disorder, was also seen retrieving and smoking cigarette butts from receptacles. Staff interviews indicated a lack of clarity regarding procedures for assessing residents' smoking safety, implementing care plan interventions, and monitoring residents while smoking. Several staff members stated they did not observe residents while smoking, and some were unaware of the presence or use of smoking aprons. Documentation in residents' records was incomplete, with smoking assessments lacking marked observations or care planning interventions. The facility's policies required assessment and documentation of residents' ability to smoke safely, but these were not consistently followed, leading to unsafe smoking practices and the accumulation of burn-related injuries and hazards.
Removal Plan
- Assessed all residents who smoke to evaluate their physical and cognitive capabilities.
- Identified residents who require supervision or adaptive equipment during smoking.
- Updated each resident's care plan to reflect safe smoking.