Inaccurate Documentation of Resident Smoking Assessment
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards for one resident. Specifically, the Safe Smoking Assessment for a resident with acute respiratory failure and Type 2 Diabetes Mellitus contained conflicting documentation regarding the resident's smoking status. The assessment, completed by an RN, indicated both that the resident was safe to smoke unsupervised and that the resident required direct supervision and a fire-resistant apron while smoking. It also stated that all smoking materials would be kept at the nurse's station and that the care plan was up to date. Interviews revealed discrepancies between the documentation and the resident's actual smoking practices. The resident reported being able to smoke unattended since admission and not being required to wear a smoking apron, although staff held her supplies and lit cigarettes for her. The RN who completed the assessment acknowledged the error, attributing it to a possible typo and was unable to recall the intended documentation due to the passage of time and working at different facilities.