Failure to Provide Required Supervision and Safety Equipment During Resident Smoking
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a history of schizophrenia, muscle weakness, and hypertension was not provided with adequate supervision while smoking, as required by physician orders and the care plan. The resident had orders for supervised smoking with a smoking apron due to an increased risk of injury, including dropping ashes on themselves and being unable to safely light or extinguish tobacco products. Despite these orders and care plan interventions, observations revealed the resident was left unsupervised in the designated smoking area on multiple occasions and was not wearing the required smoking apron. Additionally, the resident was seen picking up and smoking a discarded cigarette from another resident, further demonstrating a lack of supervision and adherence to safety protocols. Interviews with facility staff, including the Administrator, DON, and ADON, confirmed that the resident was supposed to be a supervised smoker and that the smoking apron was not being used as intended. The facility's smoking policy required staff or volunteer supervision during designated smoking times and that all smoking materials be kept in a secure area for supervised smokers. However, these procedures were not followed, resulting in unsupervised smoking and the absence of required protective equipment for the resident.