F0689

D

Failure to Enforce Smoking Policy and Maintain Effective Fall-Prevention Devices

Chillicothe, Ohio Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its smoking policy and maintain a hazard‑free environment for a resident identified as an independent smoker. The facility’s smoking policy required that residents smoke only in designated areas and that resident smoking materials be retained and distributed by staff during designated smoking times and/or when independent residents choose to smoke. The Administrator stated that independent smokers were not allowed to keep cigarettes and lighters in their rooms and were instead to lock these items in a box by the exit door to the smoking area, where they would remain until the next smoking time. However, observation showed that one resident, admitted with diagnoses including CVA with hemiplegia/hemiparesis, diabetes, and hypertension and assessed with intact cognition, had cigarettes and a lighter stored in his coat pocket in his room and reported that he believed it was permissible to store them there. The Administrator later confirmed that the written smoking policy did not address the practice of independent smokers keeping their cigarettes in a locked box by the exit door, despite that practice having been in place since around October.

The deficiency also involves the facility’s failure to consistently implement appropriate assistive devices for fall prevention for another resident at high risk for falls. This resident, admitted with dementia, COPD, schizoaffective disorder, polyneuropathy, and muscle weakness, had a BIMS score of 15 and required supervision or touching assistance with multiple mobility and ADL tasks. The resident had experienced a fall while asleep, sliding off the side of the bed, with documentation noting no injury. The care plan identified the resident as at risk for falls related to generalized weakness, and after a subsequent fall from bed while asleep, a perimeter mattress was added as an intervention. Progress notes and the care plan documented the perimeter mattress as a fall‑prevention measure, and there were no documented falls from bed after the perimeter mattress was put in place.

Later, the perimeter mattress intervention was resolved in the care plan without a fall‑prevention intervention replacing it, and bilateral assist rails (grab bars) were added under a mobility‑focused care plan rather than under fall prevention. A therapy screening by a PTA requested evaluation for grab bars in place of the perimeter mattress, but there was no documentation that the perimeter mattress negatively affected the resident’s mobility or that bed mobility with the perimeter mattress had been problematic. The DON confirmed that the resident had no falls while the perimeter mattress was in use, that the decision to initiate grab bars was discussed in a morning meeting based on a belief that the perimeter mattress might affect mobility, and that there was no documentation supporting that concern. The PTA confirmed that her screening was for mobility, not fall prevention, and that occupational therapy, which included bed mobility, had no concerns with the perimeter mattress; she also stated that, in this case, the grab bars were for mobility and not fall prevention, while the resident’s prior falls had occurred while asleep in bed.