Failure to Enforce and Update Smoking Policy and Assessments
Penalty
Summary
Facility administration failed to enforce or appropriately revise its smoking policy, resulting in inconsistent adherence to safety protocols for residents who smoke. The facility's policy required quarterly smoking safety assessments and prohibited residents from keeping smoking materials in their possession, allowing only disposable safety lighters. However, interviews with staff and residents revealed that the previous administration directed staff to relax these requirements without formally updating the policy. As a result, residents who were considered independent smokers were permitted to keep their own smoking materials and smoke at their discretion, contrary to the written policy. The Director of Nursing and current administration were unaware that required smoking assessments were not being completed. Record reviews showed that one resident began smoking after admission and kept cigarettes and a lighter in their room and on their person, with no updated smoking safety evaluation documented. Another resident's record indicated tobacco use, but quarterly smoking safety evaluations were not completed as required. A third resident's record contained no evidence of any smoking safety assessment, despite the resident being identified as an independent smoker. Staff interviews confirmed that the lack of assessments and policy adherence was due to changes in administration and a lack of awareness among current leadership.