Failure to Update Care Plan After Change in Smoking Status
Penalty
Summary
The facility failed to revise the care plan for a resident when her smoking status changed. The resident, who had a history of hemiplegia, hemiparesis following cerebral infarction, COPD, and type 2 diabetes mellitus, was initially care planned as an unsafe and supervised smoker, with interventions including a smoking safety evaluation and use of a smoking apron. However, subsequent documentation in the electronic medical record and a recent assessment indicated that the resident had quit smoking in the previous month and wished to remain a non-smoker. The annual MDS also reflected that the resident was cognitively intact and not coded for tobacco use. Despite these updates, the care plan continued to list tobacco use as a focus area and was not revised to reflect the resident's new non-smoking status.