Failure to Implement and Supervise Smoking Care Plans
Penalty
Summary
The facility failed to implement and maintain adequate supervision and care planning for multiple residents who required supervision while smoking. Record reviews for ten residents revealed that several did not have a care plan addressing smoking, despite assessments indicating the need for supervision due to cognitive impairment, physical limitations, or both. For some residents, although the care plan included supervision while smoking, the actual supervision provided was inadequate. Observations and interviews confirmed that staff assigned to monitor residents in the smoking area were not attentive. Specifically, a staff member was observed using her phone and not actively supervising approximately ten residents who were smoking. Both the administrator and the staff member acknowledged that staff were not permitted to use phones while supervising residents during smoking times, and the staff member admitted to not following this protocol. The residents involved had a range of diagnoses, including Alzheimer's disease, COPD, respiratory failure, Parkinson's disease, multiple sclerosis, schizoaffective disorder, and lack of coordination. Many had moderate to severe cognitive impairment and required supervision for activities of daily living. Despite these needs, the facility did not consistently implement or document appropriate care plans or provide the required supervision during smoking, as evidenced by both documentation and direct observation.