Failure to Develop Comprehensive Smoking Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan to address smoking for one resident. The resident was admitted with a Safe Smoking screen indicating they were safe to smoke independently and was noted as cognitively intact, using tobacco, and able to ambulate and transfer independently. Despite these findings, there was no care plan in place related to smoking as of a specific observation date. The resident was observed smoking in areas outside the designated smoking area, including the employee parking lot and another location approximately 100 feet from the designated area. Staff interviews revealed that the resident had been seen smoking on multiple occasions prior to the initiation of a care plan, but this was not documented or addressed until after a direct observation by the MDS Coordinator. The MDS Coordinator and DON confirmed that a smoking care plan was not initiated until after the resident was observed smoking, despite prior assessments and staff observations indicating the resident's tobacco use. The DON stated that the resident had denied smoking when the smoking policy was reviewed with all residents who had Safe Smoking Screening Assessments. The lack of a timely and comprehensive care plan addressing the resident's smoking behavior constituted the deficiency identified during the survey.