Failure to Complete and Update Smoking Evaluations per Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its smoking policy and procedure for a resident who smoked. The resident had diagnoses including diabetes mellitus and heart failure and was documented in a recent H&P as having the capacity to understand and make decisions. An MDS assessment indicated the resident was independent in cognitive skills for daily decision making and independent in most ADLs, with supervision needed only for showering/bathing and footwear. The facility’s smoking evaluations for this resident, dated 11/13/2025 and 2/12/2026, were incomplete and did not document smoking frequency, smoking safety, whether the care plan was updated, or whether the resident received education on safe smoking practices, risks of smoking, or locations of designated smoking areas. A care plan for noncompliance with the smoking policy, dated 3/10/2026, only indicated that the intervention was to explain smoking P&P. Record review and staff interviews showed that the facility’s policy required all residents to be assessed to determine if it was safe for them to smoke, with results placed in the medical record, and that residents’ ability to smoke safely would be reassessed quarterly and whenever there was a change in cognition. The MDS nurse stated that smoking evaluations are to be completed quarterly, annually, or with a change in condition, that the form must be completely filled out to be valid, and that she had not completed the smoking evaluation for this resident. The DON confirmed that smoking evaluations are used to determine if it is safe for a resident to smoke, are to be completed quarterly and annually, and that all sections of the form must be completed or a reason documented if the resident refuses. The resident’s medical record did not contain a reassessment of smoking ability after a change of condition on 3/10/2026, and staff acknowledged that incomplete or untimely smoking evaluations could create smoking safety issues and that failure to complete the form could mean the resident was not informed of the smoking P&P.
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