Failure to Implement Smoking Policy and Ensure Resident Safety
Penalty
Summary
The facility failed to implement its established smoking policy to ensure resident safety. Surveyors observed that the smoking policy was not posted in a conspicuous and legible manner in any resident area or common space, contrary to facility requirements. Additionally, the designated smoking area lacked required safety equipment, and residents were found to possess and use smoking materials independently, without staff supervision, and without adherence to the policy's storage and supervision requirements. Multiple residents, all identified as independent smokers with diagnoses such as COPD, emphysema, hypertension, and chronic respiratory failure, were observed smoking in the designated area without staff present. These residents had access to their own cigarettes and lighters, which they kept in their rooms or on their person, despite care plans and facility policy requiring these materials to be secured at the reception desk. Some residents also knew the door code to the smoking area and accessed it independently, further bypassing the intended supervision and control measures. Interviews with the DON and NHA confirmed that the facility's actual practices did not align with the written smoking policy. Smoking materials were not consistently secured by staff, and the smoking policy was only posted outside the smoking-area exit door, not in other required locations. The facility's failure to follow its own policy was evident in both staff and resident interviews, as well as direct observations by surveyors.