Failure to Supervise Smoking Materials and Restrain Pet Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate assessment and supervision for the use of electronic cigarettes and did not ensure the safe storage of smoking materials for a resident. Despite the facility's policy prohibiting smoking and vaping within the building and on its grounds, a resident with a history of tobacco use and cognitive intactness was observed vaping unsupervised in their room on multiple occasions. Staff were aware of the resident's vaping but did not intervene to secure the device or conduct a required smoking assessment, and there was confusion among staff regarding whether the policy included vaping devices. Documentation showed that the resident had refused nicotine patches and continued to use a vape device independently, with staff failing to follow the policy for safe storage and supervision of smoking materials. Additionally, the facility failed to supervise and restrain a staff member's dog, resulting in an accident involving another resident. The facility's pet policy required that animals be leashed and supervised at all times and prohibited their presence in dining areas. However, the dog was left unleashed and unsupervised, entered the dining room, and crawled under a table where a resident in a wheelchair was eating. The resident was startled, causing their wheelchair to tip backward, resulting in a laceration to the back of their head and requiring transport to the hospital for evaluation. Multiple staff interviews confirmed that the dog was not on a leash and that this was a direct violation of facility policy. These failures led to significant safety hazards, including the risk of fire or explosion from unsupervised vaping and a preventable injury to a resident due to the presence of an unrestrained animal in a resident area. Staff interviews and record reviews consistently indicated a lack of understanding and enforcement of facility policies regarding both smoking materials and pet supervision, directly contributing to the deficiencies identified.
Removal Plan
- Remove the smoking materials in Resident 7's room for safe storage
- Complete a smoking assessment and update Resident 7's care plan with the facility providing supervised vaping
- Interview and observe all residents and their rooms to ensure smoking materials are stored safely
- Educate all residents and/or resident representatives, and staff on the facility's non-smoking policy