Failure to Implement Fall Interventions and Enforce Safe Smoking Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain required fall-prevention interventions for one resident and to ensure safe smoking practices for another resident. One resident with a seizure disorder, fracture history, anxiety disorder, and moderate cognitive impairment had a care plan focus identifying risk for falls and injury, with an intervention specifying fall mats on both sides of the bed initiated months earlier. During observation, the resident’s bed was in a high position and the two floor mats were found folded behind a chair in another resident’s room, not on the floor beside the bed as ordered. A CNA who had been on duty since early morning reported the floor mats were not in place at the start of the shift, stated that the mats were supposed to be on both sides of the bed due to a previous fall, and noted she could not view the care plan on the computer. An RN confirmed the mats were required per the care plan and acknowledged the intervention was not set up as a CNA task, which was described as concerning given the number of new staff unfamiliar with the residents. The NHA also acknowledged concern about the missing floor mat intervention. The facility’s fall prevention policy required assessment of fall risk, development of a comprehensive plan of care including environmental hazards, and monitoring of interventions for effectiveness. The deficiency also includes failure to ensure safe smoking practices for a resident with difficulty walking, need for assistance with personal care, tobacco use, and moderate cognitive impairment. The resident was observed returning from outside in very cold, snowy conditions, wearing a heavy coat and gloves with snow on them, after going out to smoke. A CNA stated the resident went out to smoke, was “his own person,” and was supposed to go off premises, though acknowledged that in winter the resident could not traverse the deep snow and instead smoked just outside the door. Staff reported the resident smoked as often as possible, approximately every two to four hours, and that he had his own cigarettes and lighter. They also stated he was supposed to sign himself out in a lobby sign-out book, which was not present in the lobby at the time of observation. Later, the NHA was found holding the sign-out book along with the resident’s lighter and cigarettes, confirmed the items belonged to the resident, and stated the campus was non-smoking and residents could smoke off premises using the sign-out process. Review of the sign-out book showed only a few entries, all by this resident, despite staff reports that he smoked many times daily. The facility’s smoking policy stated that smoking was not permitted on facility property and that residents with smoking privileges may not retain smoking articles on their person or in their living or sleeping area at any time.
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