Failure to Supervise Resident Requiring Smoking Precautions
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure the use of a smoking apron for a resident identified as requiring supervision while smoking. The resident, who had a history of nontraumatic subdural hemorrhage, syncope, collapse, and narcolepsy, was initially assessed as safe to smoke independently. However, following an incident where the resident's clothing caught fire from a cigarette, a reassessment determined that supervision and the use of a smoking apron were necessary due to burn marks on her clothing. Despite the updated care plan and smoking assessment indicating the need for supervision and a smoking apron, the resident continued to smoke independently without staff supervision and did not wear the provided apron. Observations confirmed that the resident was able to access smoking materials, smoke outside without supervision, and did not use the smoking apron, which was found stored in her dresser drawer. Interviews with staff revealed inconsistent awareness of the resident's supervision status, with some staff considering her an independent smoker and others acknowledging the need for supervision after the incident. The Director of Nursing and Administrator acknowledged lapses in communication regarding the resident's supervision status, particularly following changes in key nursing personnel. The lack of consistent implementation of the updated care plan and supervision requirements resulted in the resident continuing to smoke unsupervised and without the required protective equipment, despite her medical history and recent incident involving fire.