cms_GA: 533
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 533 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2019-07-24 | 689 | D | 1 | 1 | I5PG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, policy review and interviews, the facility failed to provide supervised smoking for one resident (R#7) reviewed for smoking. The sample size was 55. Findings include: Review of the facility policy titled Smoke Free Policy with a revised date of 11/5/18, revealed the policy statement to be as of (MONTH) 1, (YEAR), smoking is not allowed on the healthcare center premises by visitors, partners or patients/residents. Smoking will only be allowed in outdoor designated areas for those residents grandfathered in prior to (MONTH) 1, (YEAR). Procedure bullet 10: when the patient/resident is identified as needing supervision, the supervision shall be provided by a partner who is physically present in the designated smoking area for all residents who need supervision based on their Smoking Observation Form or electronic documentation. Review of the clinical record for R #7 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Section J revealed resident was a current smoker. Review of facilities Smoker Worksheet, revealed R#7 name was on the list of identified smokers in the facility. Review of Smoking Observation Form documented that residents were to be assessed on admission, re-admission, or with a significant change. Review of Quarterly Smoking Observation Form for R#7, dated 3/12/19 and 7/22/19, revealed question one: Does the resident smoke? Yes column is checked. Question two: Does the resident have a past history of smoking? Yes column is checked. Supervision will be required at all designated smoking times when the patient/resident observation identifies any potential hazard risk, as evidenced by any boxes checked Yes. Patient/resident smoking status upon observation: Supervised Smoker. Review of document titled Smokers in the Facility undated, provided by facility, revealed that R#7 name was on the document. Review of document titled Smoking Location of the Facility undated, provided by the facility, revealed the court yard on the first floor as the designated smoking area. Based on review of R#7's comprehensive care plan a provided, resident is a current smoker and wished to continue to enjoy smoking with supervision, initiated on 3/12/19 and revised on 7/22/19. Observation on 7/21/19 at 2:00 p.m., resident was observed smoking in the designated smoking area (court yard on first floor). He was smoking one cigarette and holding a second cigarette in his hand. He was wearing a smoking apron. There was no evidence of any staff members present during the smoking period. Surveyor remained with resident until he was finished smoking. Interview on 7/21/19 at 2:00 p.m. with R#7, stated he smokes by himself most of the time, but staff give him cigarettes and light them for him, and then they leave. Observation on 7/21/19 at 2:10 p.m., staff member GG removed resident smoking apron, upon re-entry into facility. Staff member stated that he just gets the cigarettes from the nurses station and lights them for resident and puts the apron on and takes it off. He asked surveyor Is someone supposed to be outside with him when smoking? Interview on 7/23/19 at 8:45 a.m. with housekeeping aide HH, stated she was asked to start sitting with resident today, during the 8:30 smoking break. Interview on 7/23/19 at 1:21 p.m with Admininistrator, stated the facility is a non-smoking facility, but there is one resident who was grandfather in. He stated that there is not a formal schedule as to who is supposed to attend smoke breaks with the resident. He further stated that staff from housekeeping, dietary, activities and nursing are supposed to supervise the resident during smoke breaks. He further stated that he makes sure someone is with resident while smoking. On the weekends and when he is not in facility, he stated it is the responsibility of the Nursing Supervisor to ensure a staff member is with resident during smoke breaks. When questioned about Sunday episode when resident was observed in courtyard smoking unsupervised, he responded that the weekend Supervisor called out on Sunday, and he does not know who would or should have made sure the resident had supervision for smoking. | 2020-09-01 |