Failure to Update Care Plan After Change in Smoking Status
Penalty
Summary
The facility failed to review and revise the care plan for a resident following a change in smoking status, as identified through interviews and record review. The resident, an adult male with diagnoses including paraplegia, hypertension, and other conditions, was assessed as a safe and independent smoker according to a smoking assessment. Despite this assessment, the resident's care plan continued to state that all cigarettes and lighters must be stored in the medication room and that smoking was only permitted in designated areas under supervision. The care plan was not updated to reflect the resident's new status, which allowed him to keep his cigarettes and lighter per facility policy. The Director of Nursing confirmed that the care plan should have been updated after the smoking assessment, but this was not done due to the absence of the MDS nurse, who was responsible for care plan updates. The facility's policy allows residents with independent smoking privileges to keep smoking materials in their possession, but the resident's care plan did not reflect this change. This oversight was attributed to staffing issues, specifically the unavailability of the MDS nurse at the time.