Failure to Implement Smoking Safety Interventions
Penalty
Summary
The facility failed to implement care plan interventions related to smoking safety for a resident with a history of inhalant dependence and inhalant-induced dementia, who was assessed as cognitively intact. The resident's care plan required smoking only in designated areas, adherence to a smoking schedule, and storage of tobacco and fire materials in a lock box at the nurse's station. However, observations showed the resident repeatedly accessed smoking materials from the nurse's station counter, exited through the North exit door, and smoked or vaped outside of the designated smoking area, contrary to the care plan. Staff interviews confirmed that the resident was allowed to smoke independently, outside of scheduled times and designated areas, and that smoking materials were not consistently secured in the lock box as required. Additionally, staff were unclear about the frequency of required checks for burns on the resident, and the resident was observed leaving smoking materials unattended on the nurse's station counter. The Director of Nursing Services acknowledged that the only designated smoking area was the courtyard and that staff were expected to secure smoking materials immediately, but this was not consistently done. These actions and inactions resulted in the facility failing to ensure a safe environment free from accident hazards related to smoking, as outlined in the resident's care plan.