Failure to Implement Smoking Policy and Provide Designated Smoking Area
Penalty
Summary
The deficiency involves the facility’s failure to implement and enforce its own smoking policies, which require that residents deemed safe to smoke may do so only in designated smoking areas, at designated times, and in accordance with their individualized care plans. The facility’s smoke-free policy also states that smoking, including e‑cigarettes, is prohibited in all areas except a designated smoking area, and that a designated smoking area sign will be prominently posted. Surveyors reviewed these policies and then observed that there was no designated smoking area or signage on or off facility property. The Administrator acknowledged awareness that four residents smoke outside the facility and confirmed that the facility was not following its smoke-free policy because no designated smoking area had been established. Surveyors identified four residents as smokers. A RN reported that the facility is a non‑smoking facility and that residents who smoke are instructed to leave the property to do so, with their cigarettes stored in the medication cart and signed out on a log before they leave. One resident was observed independently wheeling himself in a wheelchair across uneven terrain in cold weather to an off‑property location to smoke, without staff supervision or redirection, and this location was not identified as a designated smoking area. Another resident stated he obtains cigarettes from nursing staff and is instructed to go to the public sidewalk along the street to smoke and to remain out of sight while smoking. A third resident reported he smokes twice per day and must propel himself in his wheelchair up a hill and off facility grounds to smoke, having been informed the facility is non‑smoking and that residents must go off grounds. A smoking assessment for another resident documented that the resident smokes, does not follow the non‑smoking policy, was determined able to smoke independently, and had been educated on the facility’s smoking policies and risks, yet the facility still lacked a designated smoking area as required by its own policies.
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