Failure to Enforce Smoking Supervision Policy
Penalty
Summary
The facility failed to follow its established smoking policy for two residents who were reviewed for smoking. Both residents were observed or reported to have smoked without staff supervision and to have kept cigarettes and lighters in their rooms, contrary to facility policy. Specifically, one resident was observed smoking in the designated area without staff present, and she stated that she kept her smoking materials in her purse in her room and smoked whenever she wanted. The other resident also reported keeping cigarettes and a lighter in her room and smoking at her discretion, noting that staff were not always present during smoking times. Both residents had care plans indicating the need for staff supervision or adaptations when using tobacco products. Medical records showed that both residents were cognitively intact but had diagnoses including muscle weakness, lack of coordination, and other conditions that could increase their risk during unsupervised smoking. Despite these care plans and diagnoses, the facility did not ensure that staff were present during smoking or that smoking materials were secured as required by policy. Interviews with facility staff, including the HRD, CN, and ADM, confirmed that the policy required staff supervision during smoking and that residents were not to keep smoking materials in their rooms. Staff acknowledged that unsupervised smoking could pose safety hazards, but were unaware of any injuries or incidents resulting from these lapses. The facility's written smoking policy also specified that residents requiring monitoring must be under direct supervision at all times while smoking and may not keep smoking articles except under supervision.