Failure to Complete Required Quarterly Smoking Assessments
Penalty
Summary
The facility failed to complete quarterly smoking assessments for a resident who was identified as a smoker. According to the facility's smoking policy, smoking assessments are required upon admission, quarterly, and upon any change in the resident's condition. Record review showed that the resident, who had diagnoses including hypertension, muscle weakness, dementia, and partial blindness, was admitted and coded for tobacco use on both annual and quarterly Minimum Data Set (MDS) assessments. The resident required assistance with most activities of daily living and used a wheelchair. Despite the policy, only two smoking assessments were documented within the review period, and there were missed quarterly assessments. Staff interviews revealed that Team Leaders and the Assistant Director of Nursing (ADON) were responsible for completing these assessments, with the computer system set to notify staff when assessments were due. However, both the Team Leader and the ADON were unaware that the required quarterly smoking assessments for the resident had not been completed as scheduled. The resident was observed smoking under supervision, and the care plan indicated the need for quarterly assessments, but this intervention was not consistently implemented as per policy.