Failure to Supervise Smoking Residents and Control Access to Lighters
Penalty
Summary
The facility failed to ensure that residents who require supervision while smoking were adequately monitored and did not possess their own cigarette lighters. Observations revealed that only one staff member was intermittently supervising residents during designated smoking periods, with supervision occurring through a glass window rather than direct observation on the patio. Multiple residents were seen carrying and using their own lighters, and several admitted to keeping lighters in their rooms or on their person, despite facility policy prohibiting this practice. Staff members confirmed that residents are not allowed to keep lighters due to safety concerns, and that two staff should be present during smoking times—one to distribute cigarettes and another to directly monitor the patio—but this was not consistently implemented. Record reviews indicated that the residents involved had care plans and assessments stating they required supervision for smoking and were non-compliant with turning in smoking materials. During inspections, the cigarette cart contained only two lighters, neither of which belonged to the residents observed with lighters. Staff interviews corroborated that the facility's procedures for monitoring and controlling access to smoking materials were not being followed, resulting in residents who require supervision having unsupervised access to lighters and inadequate staff oversight during smoking periods.