Failure to Prevent Smoking-Related Accident Hazards and Inadequate Supervision
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for residents who smoke. One resident with COPD, dementia, and moderate cognitive impairment was observed smoking in the lobby while on oxygen via nasal cannula, with the portable oxygen tank attached to the wheelchair. The receptionist turned off the oxygen and removed the cannula before moving the resident to the designated smoking area, but the oxygen tank remained with the resident. The Director of Nursing (DON) acknowledged that the resident was not supposed to have the oxygen tank in the smoking area and that the resident had previously been educated on this risk. A review of the resident's records revealed that the smoking assessment incorrectly indicated the resident was not a smoker, and the care plan did not address smoking, despite the resident's known smoking behavior and cognitive impairment. Another resident with vascular dementia, cognitive impairment, and physical limitations was also not properly supervised during smoking. This resident's care plan identified a risk for complications related to tobacco use and noted a refusal to use a smoking apron. The resident's smoking assessment indicated that supervision was required due to cognitive and dexterity limitations. However, the resident reported smoking unsupervised and was found to have cigarettes in his possession. Staff interviews confirmed that residents were not routinely supervised during smoking until the day of the survey, and there was no effective system in place to track or secure smoking paraphernalia as required by facility policy. The facility's smoking policy required assessment of residents' ability to smoke safely, supervision for those deemed unsafe, and secure storage of smoking materials. Despite these policies, the facility did not ensure that residents who required supervision were adequately monitored, nor did it prevent residents from possessing smoking materials outside of supervised times. These failures resulted in residents with cognitive and physical impairments being exposed to significant accident hazards related to smoking, particularly in the context of oxygen use and lack of supervision.