Failure to Develop Comprehensive Care Plan for Smoking Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident identified as a smoker, which is a requirement under §483.21(b)(1). The resident, who was admitted to the facility with diagnoses including dementia, mild cognitive impairment, adjustment disorder, and memory deficit, was assessed as cognitively intact with a BIMS score of 15. Despite the completion of a smoking assessment shortly after admission, the facility did not create a person-centered care plan addressing smoking interventions for the resident. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a comprehensive care plan for safe smoking interventions. The facility's policy mandates the initiation of a baseline care plan upon admission and a comprehensive care plan upon completion of the Care Area Assessment, but this process was not followed for the resident in question. The lack of a care plan addressing smoking was observed during a routine smoking session, highlighting the facility's failure to meet regulatory requirements for comprehensive care planning.
Plan Of Correction
Step 1 Resident R192 person centered comprehensive smoking care plan reviewed and updated to reflect residents smoking status and safe smoking interventions. Step 2 Care plan audit completed for all residents who are smokers to ensure that it reflects residents smoking status with safe smoking interventions included. Step 3 Social services, activities and nursing team educated on ensuring residents identified as smokers have comprehensive smoking care plan that reflects residents smoking status and safe smoking interventions. Step 4 Admin/Designee will conduct weekly audits x 4, monthly x2. Findings will be reviewed during QAPI meeting.
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