F0689

K

Failure to Control Smoking Materials and Supervise Unsafe Smoking, Including Oxygen-Dependent Resident

Beaver Dam, Wisconsin Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and control of smoking materials, particularly for a resident using oxygen, in violation of its own smoking safety policy. One resident with COPD and chronic hypoxic respiratory failure, who required long‑term oxygen for survival benefit per physician notes, began smoking after years of not smoking. Nursing notes documented that this resident had recently started smoking, was smoking frequently, and was observed smoking in unsafe locations, including inside the building between doors and outside the main entrance rather than in the designated smoking area. Despite multiple staff observations and documentation of this new smoking behavior, the resident did not have a Resident Safe Smoking Assessment or a smoking-related care plan, and the physician’s oxygen orders referenced in progress notes were not present on the MAR/TAR.

Staff documented repeated episodes of unsafe smoking by this oxygen‑dependent resident. Notes described the resident smoking outside with another resident, smoking so frequently that he missed meals and did not sleep, being caught smoking inside the doors with cigarette butts on the floor, and refusing to move to the designated smoking area even after being informed the facility was non‑smoking and that other residents with oxygen used the same entrance. On one occasion, police were called when the resident refused to comply with smoking restrictions at the main entrance. Later, the facility self‑reported that at approximately 3:00 AM the resident was found in his room smoking while oxygen was in use. Staff intervened, the resident refused to relinquish smoking materials, became physically aggressive, and bit a nurse’s hand while staff attempted to remove the lighter. Another nurse note documented a separate incident in which the same resident was again smoking in his room, refused to extinguish the cigarette, and began putting it out on window drapes after staff removed oxygen from the room for safety.

The facility’s own smoking policy required that smoking be limited to designated areas, prohibited oxygen use in smoking areas, mandated a Resident Safe Smoking Assessment for smokers, and required that smoking materials be maintained by nursing staff. However, the resident who had recently started smoking and was known to use oxygen had no smoking assessment, no smoking care plan, and continued to have access to smoking materials in his room. Leadership acknowledged that a safe smoking assessment was not completed, the care plan was not updated with smoking goals and interventions, and oxygen orders were not on the MAR/TAR even though staff continued to use oxygen. Additionally, surveyors observed another deficiency when one resident handed a lighter to another resident in the hallway while an LPN remained seated at the nurse station and stated that residents had the right to keep their own smoking materials, contrary to the DON’s statement that residents were to return smoking materials to staff and not hand them off to other residents. These actions and inactions show that the facility failed to secure smoking materials per policy, failed to assess and care plan for residents who smoke, and failed to ensure staff followed established smoking safety procedures.

Removal Plan

• Educated all staff on the facility smoking policy, including resident eligibility and safe smoking practices.
• Revised the smoking policy to include provisions for residents who elect to self-store smoking materials, requiring residents to demonstrate safe management and use a locked storage box in accordance with the plan of care.
• Educated staff on proper storage of resident smoking materials at the nurses station or in approved locked boxes per the resident's plan of care.
• Trained staff on immediate actions for unsafe smoking, including redirection to securing materials, addressing oxygen risks, and notifying leadership.
• Reeducated all residents who smoke on the smoking policy and requirements for keeping materials.
• Generated a comprehensive list of all residents who expressed a desire to smoke.
• Completed a smoking evaluation for each identified resident, including care plan revisions and offering smoking cessation.
• Reviewed and updated the smoking policy.
• Administrator or designee to conduct random audits of residents who smoke to ensure safe smoking and policy compliance, assessments completed, care plans in place or updated as appropriate, and correct storage of smoking materials.
• Review audit results at QAPI for further recommendations.