Failure to Safely Store Smoking Materials and Monitor Residents on Independent Pass
Penalty
Summary
The facility failed to ensure that smoking materials were safely stored and not accessible to other residents, as observed with one resident who kept a cigarette on top of the bedside table in a shared room. The resident, who had a history of smoking and multiple medical diagnoses including chronic obstructive pulmonary disease and schizophrenia, stated he kept his lighter and cigarette with him, although he had lost his lighter. Staff interviews confirmed that smoking materials are not supposed to be kept by residents and should be stored securely to prevent access by others, especially those not assessed as safe to smoke or who wander. Additionally, the facility did not adequately monitor or document the whereabouts of a resident who had independent community pass privileges. The resident left the facility without signing out, and there was no documentation of when the resident left or returned. Staff were unable to provide information on the resident's departure, and there was no evidence that required procedures, such as notifying supervisors or filing a missing person report, were followed when the resident did not return as expected. The facility's policies did not clearly outline staff responsibilities for residents on short community leaves without medications, nor did they specify actions to take when residents failed to sign out or return on time. The lack of proper supervision and adherence to facility policies regarding both smoking materials and independent community passes resulted in unsafe conditions and inadequate monitoring of residents. Staff interviews revealed gaps in knowledge and inconsistent practices related to the facility's procedures for resident safety in these areas.