Failure to Provide Required Supervision and Safety Equipment for Smoking Resident
Penalty
Summary
A deficiency occurred when a resident with a history of stroke resulting in hemiplegia/hemiparesis and unspecified psychosis, who was assessed as requiring supervision and the use of a smoking apron for safety, was not provided with the necessary supervision or safety equipment while smoking. The resident's care plan and smoking safety assessment both indicated the need for supervision and a smoking apron, yet inconsistencies were found in the documentation, with the assessment at one point incorrectly stating the resident could smoke independently. The resident confirmed that he was not wearing a smoking apron and that aprons were not available in the courtyard until the morning of the survey, despite the requirement for their use. Observations revealed that the resident was present in the designated smoking courtyard without staff supervision and without wearing a smoking apron, even though his name was listed among those requiring supervision. Staff interviews confirmed that supervision and the use of smoking aprons were required for certain residents, but the implementation of these safety measures had only recently begun, and staff were unclear about which residents required which interventions. The facility had only started using smoking aprons the day before the survey, and there was confusion among staff regarding the supervision and safety requirements for smokers. Further interviews with facility leadership acknowledged inconsistencies in the implementation of smoking safety practices, including errors in the resident's assessment and care plan. The resident was able to access the smoking area and smoke without the required supervision or safety equipment, as staff responsible for supervision were not always present, and the resident did not notify staff before going out to smoke. This lack of supervision and failure to provide required safety equipment constituted a failure to ensure the area was free from accident hazards and that adequate supervision was provided to prevent accidents.