F0689

J

Failure to Supervise Smoking and Elopement Risk Residents

Woodstock, Virginia Survey Completed on 09-26-2025

Penalty

No penalty information released

Summary

Facility staff failed to provide adequate supervision, monitoring, and use of safety devices, and did not fully implement their smoking policy for two residents. One resident, with moderate cognitive impairment and nicotine dependence, was observed independently accessing a lighter from a personal bag, lighting cigarettes for themselves and another resident, and smoking outside without a required smoking apron or proper receptacles for cigarette butts. The resident's care plan and smoking evaluation indicated the need for a smoking apron and supervision, but these interventions were not in place at the time of the incident. Staff interviews confirmed that smoking materials were not securely stored, and residents could access cigarettes and lighters outside of designated times and areas, contrary to facility policy.

Another resident, with severe cognitive impairment and dementia, was observed holding and storing partially smoked cigarettes in personal belongings, smoking unsupervised, and discarding cigarette butts in unsafe areas such as mulch with dried leaves. This resident's care plan and smoking evaluation identified them as an unsafe smoker requiring direct supervision and a smoking apron, but these interventions were not provided. Staff interviews revealed that the resident often picked up cigarette butts from the ground and smoked them, and that staff did not consistently monitor or control access to smoking materials or enforce the use of safety equipment.

Additionally, the facility failed to maintain interventions for a resident assessed as being at risk of elopement. The resident, with cognitive impairment and a history of exit-seeking behavior, had a WanderGuard device ordered and care plan interventions for monitoring, but these were discontinued without documented reassessment or justification. The resident was later observed ambulating in the facility without a WanderGuard and was not located on the secure unit, despite ongoing risk factors. Facility policy required ongoing assessment and communication of interventions for residents at risk of elopement, but these procedures were not followed.

Removal Plan

• Rooms of Resident #10 and Resident #11 have been searched and they no longer have any smoking materials.
• The responsible party for both Resident #10 and Resident #11 were notified of the incidents.
• The current smoking area on the locked dogwood unit is no longer designated as a smoking area.
• Current residents will have their rooms searched with their permission to identify any smoking materials. If smoking materials are found, they will be removed and placed in a secured storage container maintained on Rosewood unit.
• If resident refuses to have their rooms searched, the facility will respect their decision and will have increased supervision to observe for any signs of them having smoking materials [i.e. smell of smoke, burns in clothing, etc.].
• A locked container of all smoking materials, identified as belonging to which resident, will be maintained in a locked medication room on Rosewood unit.
• The activity staff or charge nurse for Rosewood unit will have access to the keys of the locked container.
• Current residents will be re-educated on the facility smoking policy.
• Any resident who desires to smoke will be provided with a written copy of the smoking policy and will be asked to sign the policy.
• If the resident is unable to sign the policy the resident's responsible party will be contacted and educated on the facility policy.
• The signed smoking policy by residents or documentation of responsible party education will be documented in the resident's medical record.
• Residents will only be allowed to smoke in the designated smoking area located in the Rosewood courtyard off the dining room equipped with smoking blankets, smoking aprons, fire extinguisher, and non-combustible self-closing ashtrays at designated smoking times.
• Current residents who desire to smoke will have their charts reviewed to ensure that the smoking assessment is current and accurately reflects any assistance/supervision and/or protective devices for safe smoking.
• The residents who desire to smoke will have their care plans reviewed to ensure that the care plan accurately reflects the assistance/supervision and safe smoking devices needed by the residents.
• All current staff, including contract staff, will be re-educated on the smoking policy and will be educated on their responsibility of what to do when they observe a resident not following the smoking policy, prior to working their next assigned shift.
• A designated person will be assigned to monitor the doorway leading to the courtyard on the locked Dogwood unit to ensure that if any resident exits into the courtyard they will not smoke.
• The Executive Director or designee will make visual observations of the smoking times on Rosewood to ensure that residents are being supervised and using protective devices for safe smoking. If variances are observed, immediate correction will be made and assigned staff for supervision will be counseled in accordance with facility protocol.
• The Executive Director or designee will make observations of the courtyard on the locked Dogwood unit to ensure there are no residents smoking or evidence that someone has been smoking in the non-smoking area.
• Findings of the observations will be monitored by the RVPO or RDCS.
• The Executive Director or designee will re-educate any resident who has been observed not following the smoking policy and discharge notice may be given for repeated non-compliance.
• Findings of the above audits will be reported to the QAPI Committee for additional oversight.