Failure to Develop Comprehensive Care Plan for Nicotine Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing nicotine use for a resident with severe cognitive impairment and a history of dementia. Upon admission and re-admission, the resident was not identified as a tobacco user, and no smoking or vaping assessments were completed. The resident's baseline and comprehensive care plans did not address nicotine or vape use, despite facility policy requiring individualized plans for residents who smoke or vape. Multiple observations and interviews revealed the resident possessed vapes at the bedside and discussed vaping, yet these behaviors were not reflected in the care plan or assessments. Nursing notes documented an incident where the resident attempted to elope from the facility to obtain a vape, resulting in the application of a wander guard. Interviews with the DON and Corporate RN confirmed that no assessments or care plans for vaping were present in the resident's record, despite the expectation that such needs would be addressed during the care planning process. Facility policies required the interdisciplinary team to develop individualized plans for safe storage and supervision of smoking materials, but this was not completed for the resident in question.