Failure to Complete and Document Smoking Assessments per Facility Policy
Penalty
Summary
The facility failed to implement its smoking policy as required, specifically by not completing smoking assessments fully or in a timely manner for three residents who used tobacco products. According to the facility's policy, residents who smoke must be evaluated upon admission, readmission, with significant change, and at regular intervals thereafter. However, documentation and interviews revealed that these assessments were either missing or incomplete at critical times, such as after readmission or during required evaluation periods. One resident with a history of acute kidney failure was admitted and later readmitted, but did not have a smoking evaluation completed upon readmission as required by policy. Another resident with chronic diastolic heart failure was also readmitted without a subsequent smoking evaluation. A third resident with polyneuropathy had a smoking evaluation on file, but the assessment was left incomplete, with the summary section blank, failing to indicate whether the resident was a safe or unsafe smoker. Interviews with facility staff, including the MDS nurse, ADON/Infection Preventionist, DON, and Administrator, confirmed that smoking assessments were not consistently completed according to the facility's policy. Some staff were unaware of the specific requirements for reassessment, and documentation in the medical records did not reflect adherence to the policy. The facility's own smoking policy clearly outlined the need for timely and complete evaluations, but these procedures were not followed for the residents reviewed.