Failure to Assess and Control Vaping/E-Cigarette Use for Oxygen-Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to evaluate and manage a resident’s vaping/e-cigarette use as part of its smoking safety program. On multiple observations, the resident was seen in bed using continuous supplemental oxygen via nasal cannula from an oxygen concentrator, with three pink vape/e-cigarette devices on the bedside table. The facility’s Smoking Protocol policy, dated 10/25/22, did not address vaping or e-cigarettes, and the resident’s Smoking Safety Evaluation, dated 11/05/25, documented that the resident did not smoke. The comprehensive assessment dated 11/17/25 showed the resident had COPD, hypoventilation syndrome, intact cognition with a BIMS score of 15, required substantial to maximum assistance with bed mobility, was dependent for bed transfers, used supplemental oxygen, and was documented as not a tobacco user. During interviews, the resident stated they were bedbound, used continuous supplemental oxygen, and vaped e-cigarettes in their room, adding that staff “turned their heads” because the resident could not go outside. The resident also reported being told by the ADON not to smoke in the room but believed this was related to their inability to get out of bed. A CNA confirmed the resident used e-cigarettes/vapes, kept them on the bedside table, did not like to get out of bed except for showers, and had confided that they vaped in the room despite nurses’ requests not to. The ADON acknowledged the resident was bedbound, on continuous oxygen, on hospice, required three to four staff for transfers, used e-cigarettes/vapes in their possession, and hid under a blanket to vape in the room, and further stated that vaping/e-cigarettes were not included on smoking assessments. The administrator also confirmed that vaping/e-cigarettes were not included in the smoking assessment or smoking policy, and stated that residents were not allowed to use vapes/e-cigarettes inside the facility.
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