Failure to Develop Comprehensive Care Plan for Tobacco and Marijuana Use After Re-Admission
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan addressing tobacco and marijuana use for a resident who was re-admitted with a documented history of marijuana use and multiple medical diagnoses, including heart failure, COPD, and nicotine dependence. Despite the resident's intact cognitive status and previous positive test for THC, the care plan did not include interventions related to marijuana or smoking following re-admission. Both the RN and DON confirmed during interviews and record reviews that no smoking care plan was present in the resident's current records, even though the resident was known to be a smoker and had previously tested positive for THC. The facility's policy requires a comprehensive, person-centered care plan to be developed within seven days of the completion of the required assessment and to be updated upon re-admission from a hospital stay. However, this process was not followed for the resident in question, as no new care plan addressing the resident's tobacco or marijuana use was created after re-admission. This omission was verified by both nursing staff and leadership during the survey.