Failure to Supervise Smoking and Investigate/Reassess Falls
Penalty
Summary
The facility failed to ensure adequate supervision for residents who smoke, as well as to thoroughly investigate falls and implement appropriate interventions to prevent future incidents. Three residents with a history of smoking were observed or documented as smoking without required staff supervision, contrary to their care plans and facility policy. One resident was found outside smoking alone and unable to re-enter the building, while two others were observed smoking in the designated area without staff present, and one was not wearing the required protective apron. Staff interviews confirmed that residents were allowed to smoke unsupervised, and documentation revealed missing or incomplete care plans for smoking safety. Additionally, the facility did not conduct thorough investigations or implement new interventions following multiple falls experienced by five residents. Medical record reviews and fall investigation reports showed repeated falls for these residents, with no evidence of root cause analysis or updated fall prevention strategies. In several cases, residents with cognitive impairments or physical limitations experienced multiple unwitnessed or witnessed falls, yet their care plans and interventions remained unchanged. Interviews with the DON confirmed the lack of documentation and absence of new interventions after these incidents. Facility policies required staff to identify and implement interventions based on residents' risks and causes of falls, and to re-evaluate and adjust interventions if falls continued. Despite these policies, the records reviewed indicated that staff did not consistently follow these procedures, resulting in repeated falls without documented efforts to address underlying causes or prevent recurrence. The deficiency was identified through medical record review, staff and resident interviews, observation, and policy review.