Failure to Complete Required Smoking Safety Screen for Resident
Penalty
Summary
The facility failed to complete a required quarterly smoking safety screen for a resident with a history of tobacco use, cerebral vascular accident, and vascular dementia. According to the facility's policy, staff are required to evaluate each resident's ability to safely use smoking materials and determine the level of supervision needed. The resident's previous assessment indicated the need for supervision while smoking, as the resident was unable to hold or extinguish cigarettes independently. However, the August 2025 Nursing Quarterly Assessment did not include the mandated smoking safety screen for this resident. Interviews with the resident confirmed ongoing participation in supervised smoking during designated times. The DON acknowledged that quarterly smoking safety screens are required and that staff nurses are responsible for completing these assessments. Upon review, the DON was unable to provide documentation of the August 2025 assessment and confirmed there was no system in place to ensure timely completion of these required evaluations.