Failure to Supervise Dependent Smoker and Maintain Updated Safety Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide required supervision and maintain updated assessments for a resident identified as a dependent smoker with a risk of wandering. The resident’s MDS dated 1/20/26 showed a BIMS score of 15 (intact cognition) and diagnoses including traumatic brain injury, aphasia, and seizure disorder. A Care Plan focus initiated 10/21/24 documented that the resident used tobacco, with a goal to adhere to the smoking policy, and interventions specifying that a dependent smoker must be assisted to designated smoking areas at designated times and supervised while smoking. A smoking assessment dated 10/21/24 indicated the resident had cognitive loss and could not light a cigarette safely, and an elopement risk assessment on the same date showed a score of 9, indicating risk to wander. The electronic health record contained no additional smoking or elopement risk assessments after 10/21/24, despite the facility’s practice of completing these at admission and annually. On 1/4/26, a nurse took the resident outside to smoke, lit the cigarette, and then returned inside, leaving the resident unattended, contrary to the Care Plan directive that staff supervise the resident while smoking. A grievance reported to the Administrator on 1/5/26 described this event, and the Administrator and DON became aware that the resident had been left unsupervised while smoking. The facility’s grievance log referenced this concern, but the resident’s electronic health record lacked documentation related to the incident, such as a progress note or incident report, even though the DON stated staff must document any occurrence outside the resident’s plan of care. The facility’s smoking policy, revised January 2024, required determining whether a resident is an independent or dependent smoker before allowing smoking, and directed that dependent smokers be supervised while smoking and have their Care Plans updated with needed safety interventions, but the facility did not consistently follow these procedures for this resident.
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