| 6280 |
COOK SENIOR LIVING CENTER |
115655 |
706 NORTH PARRISH AVE . |
ADEL |
GA |
31620 |
2015-02-05 |
280 |
K |
1 |
0 |
XT5M11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, Entity Reported Incident Intake review, facility investigative report review, resident Smoking Assessment Questionaire review, facility Smoking Policy and Procedure review, resident interview, facility staff written statement review, and staff interview, the facility failed to review and revise the Plan of Care for one (1) resident (B) who smoked cigarettes, regarding a facility-imposed restriction on the resident maintaining smoking materials and regarding staff monitoring to ensure the resident's safety; failed to review and revise the Plan of Care to reflect cigarette smoking for one (1) resident (E), who did not smoke cigarettes upon admission but later initiated smoking after admission, but for whom the facility failed to implement monitoring to ensure safety while smoking; and failed to review and revise the Plan of Care to reflect routine monitoring related to the unsafe behavior of one (1) resident (A), regarding Resident A's behavior of providing cigarettes and a lighter to another resident (Resident #1) who was assessed to require supervision while smoking. The total survey sample was nine (9) residents, all of whom smoked cigarettes. A Smoker's List provided by the facility documented a total of fifteen (15) residents who were identified by the facility to smoke cigarettes. The facility's failure to ensure adequate monitoring and supervision to residents who smoked resulted in a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The immediate jeopardy is outlined as follows: - Resident B was assessed as safe to smoke unsupervised and to posses smoking materials upon facility admission. As a result of a 2011 incident involving Resident B using a cigarette lighter unsafely, the facility restricted her possession of cigarettes and a lighter. Instead, nursing staff were to keep Resident B's cigarettes and light her cigarettes to allow her to smoke; however, the facility failed to revise the Plan of Care for Resident B, regarding the facility-imposed restriction to the resident maintaining smoking materials, and did not revise the Plan of Care to reflect any monitoring required by staff to ensure the resident's safety regarding this restriction of unsupervised access to smoking materials. During an observation on 01/23/2015, Resident B obtained a cigarette and lighter from another resident and lit the cigarette with the lighter in the absence of staff to supervise. The failure to ensure Plan of Care revision and provide routine monitoring/supervision to Resident B, allowing her to access a lighter and light a cigarette in the absence of staff supervision, placed Resident B at risk for injury. - Resident E did not smoke upon admission in June 2014, but a nurse's note of 01/20/2015 documented Resident E did smoke cigarettes, and staff interview revealed Resident E was found on 01/22/2015 while in possession of packs of cigarettes. However, the facility failed to revise the Plan of Care for Resident E, per Policy and Procedure, to reflect the resident's post-admission initiation of cigarette smoking, and failed to implement any routine monitoring to ensure the resident's safety while smoking. - Resident A was assessed to be safe to smoke without staff supervision and was allowed to maintain his cigarettes and cigarette lighters in his possession. Resident A's Plan of Care identified that Resident A smoked cigarettes, and indicated that no staff supervision was needed during smoking. Resident A had a known history of providing cigarettes and lighter access to Resident #1 (who was assessed by the facility to be unsafe to smoke without staff supervision and was not to have possession of cigarettes and a lighter). The facility counseled Resident A related to this unsafe practice of providing smoking materials to Resident #1 in the absence of staff supervision; however, the facility failed to revise the Plan of Care for Resident A to implement any monitoring regarding his unsafe practice of providing smoking materials to Resident #1 and allowing Resident #1 to smoke in the absence of staff supervision. Then, on 01/19/2015, Resident A provided two (2) cigarettes to Resident #1, who also gained access to Resident A's lighter and attempted to light a cigarette, at which time she ignited her hair with the lighter. Resident #1 was transferred to the Burn Center, treated for [REDACTED]. Even though Resident A was found to again provide Resident #1 with a cigarette on 01/24/2014, the facility still failed to revise the Plan of Care for Resident A to put a system of monitoring into place, related to Resident A's ongoing unsafe behavior of providing smoking materials to Resident #1 without the knowledge of facility staff. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on January 30, 2015 at 12:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on January 19, 2015, the date Resident #1, who was assessed by the facility to require staff supervision while smoking, obtained two (2) cigarettes and a cigarette lighter without staff knowledge, attempted to light the cigarette with the lighter, and caught her hair on fire with the lighter. Resident #1 sustained multiple second/third [MEDICAL CONDITION] the left face, forehead, and ear. The immediate jeopardy continued through February 2, 2015, and was removed on February 3, 2015. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 2, 2015. An allegation of jeopardy removal was received on February 2, 2015. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 3, 2015. The facility remained out of compliance at a lower scope and severity of E while the process of evaluating modifications of resident assessment systems, care planning systems, and processes involved in the supervision of residents who smoked continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's processes for supervising residents who smoked and who required supervision during smoking. Resident record reviews were conducted to assess facility staffs' conformance with the development of resident Plans of Care regarding smoking supervision. In addition, residents were observed while smoking in the exterior designated smoking area to assess facility staffs' conformance with the supervision of residents while smoking, in accordance with their assessed needs and as specified by their Plans of Care, to therefore ensure resident safety while smoking. Findings include: Review of the facility's Smoking Policy and Procedure revealed the Procedure to specify that residents were to be assessed using the Smoking Assessment Questionaire upon admission, quarterly, and with any change in condition regarding smoking preferences and specific needs. This assessment was to include, but not be limited to, cognitive concerns, the level of assistance needed to smoke (i.e., assistance with lighters, holding of cigarettes), and any safety concerns. Based on the data collected during this assessment process, a specific plan was to be developed to meet the individual needs of the resident. The resident-specific information from the assessment was to be included in the resident's Plan of Care, which was to be reviewed and revised accordingly. 1. Resident B's Annual Minimum Data Set (MDS) assessment of October 2014 documented an original admission in March 2010, and documented in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) Summary Score of 13, indicating she was cognitively intact. Section I - Active [DIAGNOSES REDACTED]. A Smoking Assessment Questionaire dated 10/30/2014 for Resident B referenced the resident's history of tobacco use. This Smoking Assessment Questionaire assessed Resident B's current status related to cigarette smoking, and assessed the resident as safe to smoke without supervision. During a 01/23/2015, 12:00 p.m. interview, Resident B acknowledged that she smoked without supervision, but stated she could not keep her cigarettes and lighter; rather, staff kept her cigarettes and lighter, and the nurse would light cigarettes for her to smoke. During a 01/29/2015, 2:20 p.m. interview, the DON stated that Resident B was allowed to keep her cigarettes and lighter in the past, but was involved in a 2011 incident during which she used a cigarette lighter to light tissue paper on fire. The DON stated that, due to the 2011 incident, Resident B no longer kept her smoking materials, but instead, nursing staff kept the resident's cigarettes and lighter. However, review of Resident B's current Plan of Care revealed no reference to the resident's use of cigarettes, and there were no Plan of Care Interventions related to the resident's cigarette use (to include no reference to the requirement that nursing staff were to maintain the resident's cigarettes and lighter secured). This was despite the fact that Resident B, although assessed to be capable of smoking without supervision (per the 10/30/2014 Smoking Assessment Questionaire referenced above), had been allowed in the past to maintain her smoking materials, but had subsequently been restricted from keeping cigarettes and a lighter on her person due to a 2011 incident involving a cigarette lighter (per the 01/29/2014, 2:20 p.m. DON interview referenced above). This was also despite the facility's Smoking Policy and Procedure referenced above which specified that residents would be assessed with [REDACTED]. The facility had therefore failed to review and revise the Plan of Care for Resident B after the 2011 incident resulting in a restriction of her having access to smoking materials, including cigarettes and the cigarette lighter, in the absence of staff supervision. During an interview with the facility's Care Plan (CP) Coordinator conducted on 02/02/2015 at 1:44 p.m., the CP Coordinator acknowledged that for residents requiring supervision while smoking, Plans of Care should include resident cigarette use and interventions for supervision. During a 01/23/2015, 12:45 p.m. observation, Resident B was in the smoking area with Resident #3 with no staff in attendance. During this observation, Resident B asked Resident #3 for a cigarette. Resident #3 handed a cigarette and lighter to Resident B, who then lit the cigarette and began smoking. Based on the above, Resident B was admitted to the facility in 2010 and was assessed to be safe to smoke without supervision. Due to a 2011 incident involving Resident B's unsafe use of a cigarette lighter, the facility then restricted Resident Bs access to cigarettes and a lighter. Nursing staff were to maintain the resident's smoking materials and light the resident's cigarettes. However, the facility failed to revise Resident B's Plan of Care, as specified by the Smoking Policy and Procedure, to reflect the plan developed by the facility regarding the resident's use of cigarettes, developed in 2011, to restrict Resident B's access to smoking materials. Cross refer to F323, example 2, for more information regarding Resident B. 2. Resident E's Admission MDS assessment of July 2014 documented admission in June of 2014. Section I - Active [DIAGNOSES REDACTED]. Section J - Health Conditions documented that Resident E did not use tobacco products upon facility admission. A Smoking Assessment Questionaire for Resident E dated June of 2014, completed upon the resident's facility admission, documented that the resident was non-smoking. But, a subsequent Smoking Assessment Questionaire of 12/22/2014 then assessed Resident E for smoking, indicating that Resident E was not safe to smoke without staff supervision. A NPN entry of 01/20/2015 at 10:00 a.m. documented that Resident E did smoke cigarettes in the designated smoking area, and Resident E acknowledged, during a 01/23/2015, 10:45 a.m. interview, that he did smoke. During a 01/30/2015, 10:45 a.m. interview, Licensed Practical Nurse (LPN) CC stated she had observed Resident E on 01/22/2015 to have multiple packs of cigarettes. However, even though Resident E's 12/22/2014 Smoking Assessment Questionaire (referenced above) documented that the resident required supervision while smoking, and even though the July 2014 MDS assessment (referenced above) documented Resident E did not smoke upon admission, but then the resident began smoking after facility admission (as acknowledged in Resident E's 01/23/2015, 10:45 a.m. interview referenced above), and smoked with the knowledge of facility staff (as documented in the 01/20/2015, 10:00 a.m. NPN, and acknowledged during LPN CC's 01/30/2014, 10:45 a.m. interview, both referenced above), review of Resident E's Plan of Care revealed no reference to the resident smoking cigarettes, and no Plan of Care Interventions related to the resident's cigarette use. This was despite the facility's Smoking Policy and Procedure referenced above which specified that, upon any change, the resident's specific smoking needs (including the need of nursing staff to provide assistance with lighters and holding of cigarettes) would be included in the Plan of Care. The facility had therefore failed to review and revise the Plan of Care for Resident E upon the resident's initiation of smoking activities after his June 2014 facility admission. During an interview conducted on 02/02/2015 at 1:44 p.m., the CP Coordinator acknowledged that Plans of Care for residents who smoked should include interventions for supervision during smoking if required. Cross refer to F323, example 3, for more information regarding Resident E. 3. Resident A's Admission MDS assessment of December 2014 documented the resident's admission that month, and Section C - Cognitive Patterns documented Resident A with cognitively intact, having a BIMS Score of 15. Section J - Health Conditions documented that Resident A used tobacco products at the time of facility admission. A December 2014 Smoking Assessment Questionaire for Resident A assessed the resident to be safe to smoke without supervision. During a 01/29/2014, 9:50 a.m. interview, the Administrator stated that some residents assessed as safe to smoke independently (such as Resident A, per the Smoking Assessment Questionaire referenced above) were allowed to keep smoking paraphernalia (cigarettes and lighters) in their possession. Review of the Plan of Care for Resident A revealed a Problems/Strengths entry of 12/21/2014 which identified that the resident had altered thought process potential. Interventions on this Plan of Care for Resident A, as related to the resident's altered thought process potential, included a notation that the resident was a smoker, but noted that no supervision was needed for smoking. A Social Progress Notes (SPN) entry for Resident A dated 12/29/2014 (approximately one week after the 12/21/14 development of Resident A's Plan of Care Intervention, referenced above, which indicated the resident required no supervision during smoking) documented that Social Services staff had counseled with Resident A to inform him not to give cigarettes or light cigarettes for a female resident (Resident #1), because the female resident was on a supervised smoking program with staff supervision only. However, despite the SPN entry of 12/29/2014 referenced above which identified Resident A's having been counseled regarding providing cigarettes to, and lighting cigarettes for, Resident #1 who required supervised smoking, further review of Resident A's Plan of Care revealed no revisions related to any acknowledgement of this behavior of Resident A's unsafe practice of inappropriately providing Resident #1 smoking paraphernalia, nor any Intervention to address this unsafe practice. Entity Reported Incident Intake (ERII) Number GA 603 of 01/21/2015, submitted to the State Agency by the facility regarding Resident #1, then documented that Resident #1 smoked cigarettes and required supervision, but that on 01/19/2015, Resident #1 obtained two cigarettes and a lighter from another resident and caught her hair on fire. A facility investigative report of 01/22/2015 documented that Resident #1 and Resident #9 were in the smoking area and, per Resident #9, Resident #1 produced a hand-rolled cigarette and lighter. Resident #1 attempted to light the cigarette but accidentally lit her hair on fire. Resident #9 informed Resident C, who smothered the fire on Resident #1's head. Resident #1 was transferred to the hospital and noted with second/third [MEDICAL CONDITION] the left side of the face, third [MEDICAL CONDITION] the left side of the forehead/temple, and second [MEDICAL CONDITION] the left side of the cheek and external ear, and was transferred to the Burn Center. This investigative report documented that Resident A admitted he gave Resident #1 two cigarettes and that Resident #1 could have obtained the lighter from his room, and documented a facility conclusion that Resident A provided rolled cigarettes to Resident #1. However, despite the ERII and investigative summary referenced above documenting the 01/19/2015 incident during which Resident A had again given cigarettes to Resident #1 (with Resident #1 then gaining access to a lighter, ignighting her hair and sustaining multiple burn wounds to her face, forehead, and ear), further review of Resident A's Plan of Care still revealed no notation regarding Resident A's unsafe behavior of providing Resident #1 cigarettes and allowing her access to his cigarette lighters. Then, a NPN entry of 01/24/2015 at 9:22 a.m. for Resident A documented that Resident A had again given a resident (Resident #1) a hand-made cigarette, and that Resident A was again counseled to refrain from giving any resident a cigarette or lighter. In a written statement, RN EE documented the 01/24/2014 incident (as documented in the 01/24/2015, 9:22 a.m. NPN entry referenced above) during which Resident A had given Resident #1 a hand-made cigarette, and that staff were instructed to monitor Resident #1 and Resident A for the exchange of smoking paraphernalia. However, despite Resident A again have provided Resident #1 with a cigarette on 01/24/2015 (per the 01/24/2014, 9:22 a.m. NPN referenced above), and even though staff were specifically instructed to monitor Resident A (and Resident #1) closely regarding the exchange of smoking materials, further review of Resident A's Plan of Care still revealed no revision to reflect Resident A's continued unsafe behavior of providing Resident #1 with smoking paraphernalia, nor did the Plan of Care reference any Interventions to address this unsafe practice at that time. During a 02/02/2015, 1:44 p.m. interview, the CP Coordinator acknowledged that resident Plans of Care should include interventions for supervision regarding cigarette use. Cross refer to F323, example 1, for more information regarding Resident A (in relation to Resident #1). The facility presented a credible allegation of jeopardy removal (CAJR) on February 2, 2015. Based on the CAJR, it was determined that the immediate jeopardy had been removed on February 3, 2015, at which time the facility had implemented the following interventions: 1. On 01/26/2015, the Quality Assessment and Assurance (QAA) Committee met. During this meeting, the QAA Committee reviewed the facility's current Smoking Policy and discussed revisions to enhance resident safety. Recommendations were made, and the DON was to make edits and submit the revised Policy for review and approval. The specific recommendation that all resident smoking would be monitored was discussed an initiated immediately. Additionally, the Committee discussed offering smoking cessation services to residents desiring such services. 2. On 01/27/2015, the QAA Committee met and the revisions to the Smoking Policy were submitted for review and approval. The QAA Committee meeting focused on the development of a Smoking Monitoring Log, with approval and implementation post meeting. This Smoking Monitoring Log would allow for the staff responsible for monitoring the smoking area (per the newly implemented procedure referenced above specifying that all resident smoking would be monitored) to document attendance and oversight during designated smoking times. The QAA Committee was informed that a smoking cessation instructor would begin services on that date, offering a general orientation to smoking cessation classes. 3. On 01/29/2015, the facility implemented the Smoking Policy, the Purpose of which is to provide guidance regarding resident smoking at the facility. This Smoking Policy includes, but is not limited to, the specification that resident smoking is only permitted under staff supervision. Residents will not be allowed to keep any smoking paraphernalia on their person or with their personal belongings. Residents are required to check smoking paraphernalia out from staff members with entrance to the designated smoking area, and check smoking paraphernalia back in with staff at the time of exit from the designated smoking area. No more than two (2) cigarettes may be distributed to a resident, and any cigarettes not smoked will be collected by staff and returned to the storage area upon reentry into the building. Lighters and matches will be distributed to the resident for that smoking session and collected by staff for storage upon reentry into the building. Smoking paraphernalia will be inventoried following every smoking session to ensure all is accounted for. This inventory will be completed by the staff member assigned to supervise at each scheduled smoking time, and will be documented on the Resident Tobacco and Paraphernalia Log. The sharing of cigarettes and/or lighters and matches amongst residents is not permitted. Smoking is not permitted except within the designated area which is the courtyard/patio area located on the facility's South wing. Resident smoking will be conducted during scheduled times via a Smoking Schedule, and the smoking area will be open for resident access based on the posted schedule. Additionally, the Smoking Policy specifies that residents will be assessed upon admission regarding smoking preferences and any special needs. Residents are then reassessed quarterly and with any change in condition. A Smoking Safety Evaluation Form will be utilized to conduct resident smoking assessments. This Smoking Safety Evaluation will be utilized to assess a resident's smoking history, safety concerns, cognitive awareness, and ability to handle a lighter. This assessment includes the evaluation of each smoking resident's capabilities and deficits and determines whether or not supervision during smoking is required. Based on the data collected in the smoking assessment, a specific plan will be developed to meet the individual needs of the resident. The information in the assessment is included in the resident's Plan of Care, which is reviewed and revised accordingly. 4. On 01/29/2015, the facility implemented the use of a new Safety Surveillance Log to be utilized in the event of resident non-compliance with the Smoking Policy. This new procedure indicated that, in the event a resident is observed in possession of tobacco and/or paraphernalia (other than at the approved times and in conformance with approved procedures), the facility would implement surveillance to ensure compliance. Said surveillance will be documented in the Safety Surveillance Log. At the time of discovery of an infraction, items will be inventoried for the resident. The Safety Surveillance Log will be completed as supervised by the designated Charge Nurse. The surveillance frequency will be a minimum of twice per day, and include a random search for a seven-day period. With zero findings for the seven-day period, the surveillance would transition to three times per week for 30 days. A reassessment will be conducted post the 30 day mark for the necessity of ongoing surveillance. In addition, an attempt will be made to identify the source of provision of products with subsequent counseling to follow. All findings and recommendations will be submitted to, and monitored by, the QAA Committee. 5. On 01/29/2015, a special called Resident Council meeting was held to discuss the changes to the Smoking Policy. All resident smokers were in attendance. 6. On 01/29/2015, all residents utilizing tobacco products were assessed by the DON using the new Smoking Safety Evaluation Form. One-hundred percent of all current residents who smoke (a total of fourteen residents on the date of assessment) were assessed with [REDACTED]. 7. On 01/29/2015, the facility reviewed/revised the Plans of Care for all residents using tobacco products, and Plans of Care for these residents were developed/updated with the goals of no injury when using tobacco products, safety practices, and encouraging smoking cessation. 8. On 01/29/2015, the facility reiterated a procedure requiring that the facility's Interdisciplinary Care Team reassess each resident who smoked on a quarterly basis, or more frequently if needed, to determine if any change in smoking abilities has occurred. All resident Plans of Care will be updated to reflect this assessment. 9. On 01/30/2015, a one-on-one sitter was assigned to Resident #1 to provide supervision to the resident. Resident #1 will have a sitter twenty-four hours per day, seven days per week to ensure her safety, and this coverage will continue until a later determination is made. 10. On 02/02/2015, the facility implemented the use of fire blankets (which were originally ordered by the facility on 01/30/2015). These fire blankets will be housed in the smoking area and will be used to aid in ensuring resident safety during smoking. 11. On 02/02/2015, the facility implemented enforcement of the Policy by which all smoking tobacco products and paraphernalia were removed from resident possession. Going forward, per the new Policy referenced above, smoking tobacco products and paraphernalia will be provided to residents upon request in the designated smoking area. When the resident reenters the facility after smoking activities have concluded, any smoking tobacco product that has not been consumed, as well as any smoking paraphernalia, will be returned to facility staff and inventoried. 12. On 02/02/2015, the facility conducted staff in-service training regarding the new Smoking Policy and the new procedures involving the supervision of residents who smoke, the new smoking schedule, the monitoring process for potential resident noncompliance, and resident safety while smoking by the use of fire blankets. This staff in-service training also included staff training related to the smoking assessment process. As of 02/02/2015, the following facility staff had received this in-service training: eighteen (18) of eighteen (18) housekeeping staff; fourteen (14) of fourteen (14) food service staff; three (3) of three (3) activities staff; forty (40) of forty (40) certified nursing assistants; and twenty-two (22) of twenty-three (23) licensed nursing staff. One (1) licensed nursing staff member was unavailable to receive this training due to being on leave status. This one (1) remaining licensed nursing staff member will receive this in-service training upon her return to work. 13. On 02/02/2015, the facility implemented the Smoking Policy Compliance Audit to audit the facility's new smoking program to monitor for evidence of ongoing staff compliance. This Audit will serve the purpose of monitoring and assessing staff compliance with the routine completion of the resident Smoking Safety Evaluation assessments, execution and maintenance of resident Plans of Care, the completion of the routine staff inventory of tobacco products and paraphernalia, and completion of the Smoking Surveillance Log (utilized as needed to address identified resident noncompliance with the Smoking Policy). This Smoking Policy Compliance Audit will be conducted by the DON, Assistant Director of Nursing, designated Registered Nurse Supervisor, Administrator, Assistant Administrator, or MDS Coordinator. This Audit will be conducted on every resident who smokes beginning on 02/02/2015, and will be conducted with the following progression: Weekly from 02/02/2015 through 02/28/2015; Biweekly from 03/01/2015 through 04/05/2015; Monthly on 04/06/2015, and ongoing. Any findings and subsequent interventions for ongoing compliance with facility Policy will be discussed with the QAA Committee. The data collected during the Smoking Policy Compliance Audit will be reported monthly to the QAA Committee for the Committee's review and evaluation. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the facility's QAA Committee had convened to review the facility's Smoking Policy, discuss Policy revisions, and instruct the DON to make specified Policy changes. This was in accordance with Step #1 of the CAJR referenced above. - On 02/03/2015, interview with the Administrator and review of QAA Committee attendance sheets confirmed that the QAA Committee met for review and approval of the revisions to the Smoking Policy. This included the development and implementation of the Smoking Monitoring Log to be used by staff to ensure attendance and oversight during resident designated smoking times. This was in accordance with Step #2 of the CAJR referenced above. - On 02/03/2015, DON interview and Policy review confirmed that the facility had implemented a new, revised Smoking Policy with specifications which included the restriction of resident smoking to scheduled smoking times and under direct staff supervision only, the restriction of residents' possession of smoking paraphernalia in the absence of staff supervision. This Smoking Policy also specified a procedure involving residents obtaining smoking paraphernalia from staff when entering the smoking area and returning smoking paraphernalia to staff upon exiting the smoking area. This was in accordance with Step #3 of the CAJR referenced above. - On 02/03/2015, document review, Policy review, and interview with the DON confirmed that the facility had implemented the Safety Surveillance Log to be utilized in the event of resident noncompliance with the Smoking Policy (and to be used on an as-needed basis). This new Safety Surveillance Log and the accompanying procedure would allow staff to implement surveillance, via inspections at specified intervals for specified timeframes, to ensure resident compliance with the facility's Smoking Policy. This was in accordance with Step #4 of the CAJR referenced above. - On 02/0 (TRUNCATED) |
2018-02-01 |