Failure to Provide Adequate Supervision to Prevent Misuse of Smoking Products
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents, specifically related to the misuse of a smoking product containing THCA. The resident, a male with multiple diagnoses including COPD, bipolar disorder, hypertension, generalized anxiety disorder, and a cardiac pacemaker, was assessed as cognitively intact and required supervision with all activities of daily living. Despite documented behavioral issues such as not following the smoking policy and drug-seeking behavior, the resident was allowed to keep smoking materials and smoke unsupervised, as indicated in his care plan. Multiple progress notes and staff interviews revealed ongoing incidents where the resident was observed or suspected of using marijuana or THCA products both inside and outside the facility. Staff reported smelling marijuana on the resident and witnessing him rolling and smoking substances labeled as THCA, which he claimed to have purchased legally from a nearby store. The resident was also noted to sign himself out of the facility to smoke and would return smelling of marijuana. The facility's policy allowed residents assessed as safe smokers to keep their smoking materials, but the resident repeatedly violated designated smoking areas and times, and brought non-tobacco substances into the facility. Despite repeated violations and behavioral issues, the facility's interventions were limited to education, confiscation of visible substances, and attempts to discharge the resident, which were reversed by the state agency. The facility did not provide evidence of additional supervision or changes to the resident's care plan to address the ongoing misuse of smoking products. The facility's smoking policy required evaluation of residents' ability to smoke safely and allowed for confiscation of items in violation, but staff stated they could not search the resident's belongings without violating his rights. The facility's drug policy was requested but not provided by the time of the survey exit.