Failure to Reassess Smoking Safety and Secure Smoking Materials Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that staff re-assessed a resident's smoking status and updated the care plan following a significant change in the resident's cognitive condition. The resident, who had a history of cigarette smoking and was at risk for injury and inappropriate behaviors, experienced a decline in cognition as documented by a lower BIMS score. Despite this significant change, the resident's smoking safety was not re-evaluated, and the Minimum Data Set (MDS) inaccurately reflected no tobacco use. The medical record lacked a corresponding Smoking Safety evaluation and care plan update after the change in condition. Additionally, after an incident where the resident was found smoking inside their room while using oxygen, staff did not complete a new smoking safety assessment or update the care plan as required by facility protocol. The Activity Director and DON confirmed that the event should have triggered a reassessment and care plan revision, but these actions were not taken. The resident's medical record did not reflect any follow-up or documentation of the incident in the smoking safety evaluation. Furthermore, the facility failed to secure the resident's lighter and cigarettes, contrary to the facility's protocol that prohibited residents from retaining smoking paraphernalia. Despite the implementation of a new smoking program protocol, the resident was able to access smoking materials and subsequently caused a fire in their room while using oxygen. This resulted in the resident sustaining burns and smoke inhalation, requiring hospitalization.