Failure to Accurately Individualize Smoking Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that accurately reflected the smoking status and required level of care for three residents. For each of these residents, there were discrepancies between their assessed ability to smoke safely and the interventions documented in their care plans. Specifically, care plans indicated that residents required supervision while smoking, despite smoking evaluations and staff interviews confirming that some residents were safe, independent smokers who did not require supervision, while another was assessed as an unsafe smoker who should not have been allowed to smoke independently. Resident records showed that assessments, such as the Minimum Data Set (MDS) and smoking evaluations, were completed and indicated the residents' cognitive status and smoking safety. However, the care plans were not updated to reflect these assessments. Staff interviews revealed that the care plans were often not individualized, with some staff relying on self-populated templates without editing goals and interventions to match the residents' current needs. This led to care plans that did not accurately represent the residents' smoking status or the facility's actual practices regarding supervision and safety measures. Facility policy required that care plans be specific, individualized, and based on interdisciplinary assessments, including the degree of supervision necessary for residents who smoke. Despite this, the care plans for the three residents did not align with their most recent smoking evaluations or the facility's smoking policy. Interviews with nursing staff, the DON, and the administrator confirmed that the care plans were inaccurate and not up to date, and that staff did not always understand the need to personalize care plans beyond the default information provided by the electronic system.