Failure to Secure Smoking Materials and Provide Supervision
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents, specifically regarding the management of smoking materials. Observation revealed that a female resident with diagnoses of unspecified schizophrenia and Alzheimer's disease, and a BIMS score indicating intact cognition, was found holding a pack of cigarettes while sitting near the nurse's station. Staff were aware of the resident's possession of cigarettes but did not retrieve them, citing concerns that doing so would upset her. The resident was later observed still holding the cigarettes and requesting to be taken outside to smoke, although she did not have a lighter in her possession. Review of the resident's care plan and smoking assessment indicated that she required staff supervision while smoking due to her cognitive status. The care plan did not initially document the practice of allowing the resident to hold her cigarette pack, and facility policy required that smoking materials be kept secured at the nurse's station, with residents without independent smoking privileges not permitted to have smoking articles except under direct supervision. The administrator acknowledged that staff provided the resident with cigarettes to calm her, despite the policy and care plan interventions, and recognized the potential danger if the resident obtained a lighter.