Failure to Include Smoking and Oxygen Use in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission that addressed a resident's smoking needs, including the resident's use of oxygen, despite documented nicotine dependence and respiratory failure. The resident was admitted with these diagnoses, and a smoking assessment indicated that the resident was capable of holding their own cigarette and smoking unsupervised, with the requirement that nursing secure the lighter and make it available as needed. Nursing progress notes documented that the resident went to smoke multiple times and had to be repeatedly reminded to wear oxygen. However, the baseline care plan in effect from the resident's prior residential care unit admission did not address the resident's smoking status or oxygen use until a later date. The deficiency culminated in an incident in which the resident, while on oxygen, went to the smoking room and had another resident light a cigarette. After taking two puffs, the cigarette caught fire in the resident's face, burning the oxygen tubing and leaving black soot on the resident's nose. The resident sustained a painful superficial burn to the face, including loss of skin from the tip of the nose, with specific measurements documented in the nursing notes. During an interview, the ADON confirmed that the residential care unit care plan served as the baseline care plan on admission and was unable to provide documentation that the baseline care plan addressed the resident's smoking needs until the day after the burn incident, contrary to the facility's smoking policy requiring smoking-related privileges, restrictions, and concerns to be noted in the care plan and communicated to staff.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.