Failure to Implement and Document Required Smoking Policy and Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow its smoking policy and standard care plan procedures for multiple residents who smoked. For seven residents with various medical conditions, including end stage renal disease, COPD, cardiovascular disease, diabetes, and psychiatric and neurologic diagnoses, the clinical record review showed either no initial identification of smoking risk on the care plan or, when smoking risk was identified, the required physician orders for smoking were absent. One resident’s care plan initially lacked any identified smoking risk, and another resident’s smoking activity was only documented under activities interests as a desire to be included in smoke breaks, without a corresponding smoking risk care plan. In all reviewed cases, the residents had signed smoking contracts acknowledging the facility’s smoking policy. Further review of the care plans for several residents showed a standardized problem of “risk related to smoking” with interventions that explicitly required an MD-signed order, consent signed by the responsible party, smoking only with supervision in a designated area, and quarterly smoking assessment per protocol. Despite these written interventions, the physician order sections of the records contained no smoking orders for any of the seven residents. The facility’s written policy, “Resident Smoking,” stated that smoking safety is included in the Standard Care Plan and reviewed at least quarterly, and the Standard Care Plan specified that an MD order is required, smoking is allowed only with supervision at designated times and locations, and smoking supplies are to be left with personnel. Staff interviews revealed a lack of awareness and inconsistent practices regarding identification and management of residents who smoke. A CNA reported she was unsure where in the chart a resident’s smoking status was documented and learned who smoked only when other staff informed her; she also stated she did not know the smoking policy. An LPN stated he knew which residents smoked based on familiarity and did not think residents needed a smoking order, believing that signing the contract was sufficient, even though he read aloud from a care plan that an MD order was an intervention. The admissions coordinator stated she was not often aware of smoking status at admission, sometimes documented it when known, and did not know the full policy beyond designated times and the need for accompaniment. The DON stated all residents sign the smoking contract regardless of smoking status and acknowledged not being aware of the smoking policy beyond the contract, noting that without smoking orders providers may be unaware of residents’ smoking status. The administrator stated the smoking policy includes supervision and use of smoking aprons and, after reviewing the policy, indicated that the care plan interventions were part of that policy.
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