Failure to Develop Person-Centered Care Plans for Smoking and Pass Privileges
Penalty
Summary
Surveyors identified a failure to develop person-centered comprehensive care plans addressing smoking and going out on pass for two residents. For the first resident, who was admitted with heart failure and diabetes and was assessed on the MDS as cognitively intact and independent in all ADLs, physician orders dated in January 2026 authorized the resident to smoke and to go out on pass. During a concurrent interview and record review, RN 1 confirmed that the resident’s care plan did not contain any interventions or approaches related to smoking or going out on pass, despite these active physician orders. For the second resident, who was admitted with cellulitis of the back and assessed on the MDS as having little to no cognitive impairment and being independent in all ADLs, physician orders dated in January 2026 also authorized the resident to smoke. During interview and record review, RN 1 confirmed that there was no care plan addressing smoking for this resident. The Administrator stated that the DON was responsible for ensuring resident care plans were completed, but the DON was not available for interview. The facility’s written policy on comprehensive plans of care required development of a comprehensive, measurable, interdisciplinary care plan that addresses resident needs, strengths, preferences, and risk factors, and is periodically reviewed and revised with resident participation.
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