Failure to Provide Adequate Supervision During Resident Smoking Activities
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision for two residents who wished to smoke, as required by the facility's policy and procedure on resident smoking. On the observed date and time, the Activities Assistant (AA) responsible for supervising the smoking patio was seated inside, facing away from the door and unable to visually monitor the residents who were smoking outside. The AA acknowledged not being able to see the residents from their position and stated that visual supervision was important to ensure resident safety and prevent incidents such as burns or altercations. Resident 4 had a history of peripheral vascular disease and lack of coordination, with care plans and assessments indicating a risk for injury related to smoking and a need for supervision during smoking activities. Resident 5 had diagnoses including peripheral vascular disease, muscle wasting, and nicotine dependence, and was also identified as being at risk for injury from smoking or vaping, requiring staff supervision during scheduled smoking times. Both residents' care plans and assessments documented the need for precautionary measures and supervision, and facility policy specified that residents requiring assistance or monitoring for smoking safety were not to smoke unsupervised. Interviews with staff, including an LVN and the Director of Nursing (DON), confirmed that residents were not permitted to smoke without supervision due to safety concerns such as burns, altercations, or potential fires. The DON emphasized the necessity of maintaining visual contact with residents during smoking activities. Despite these requirements, the observed lack of direct supervision placed the residents at risk and constituted a failure to follow established safety protocols.