| 6281 |
COOK SENIOR LIVING CENTER |
115655 |
706 NORTH PARRISH AVE . |
ADEL |
GA |
31620 |
2015-02-05 |
281 |
K |
1 |
0 |
XT5M11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, facility investigative report review, resident Smoking Assessment Questionaire review, resident interview, facility staff written statement review, National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules review, and staff interview, the facility failed to ensure routine surveillance and monitoring regarding cigarette smoking, in accordance with professional standards of practice, for one (1) resident (#1) who was assessed by the facility to require supervision while smoking, but for whom the facility failed to ensure routine monitoring regarding the resident's unsafe behavior of obtaining smoking materials without staffs' knowledge; for one (1) resident (B) who smoked without supervision but who had a restriction on her access to a cigarette lighter; and for one (1) resident (E), who did not smoke at the time of facility admission but began smoking cigarettes after admission, but for whom the facility failed to provide routine monitoring to ensure the resident's safety during 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 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 #1 required staff supervision while smoking, and nursing staff kept her smoking materials locked, but Resident #1 had a history of [REDACTED]. However, despite the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice specifying that the nurse provide monitoring, facility nursing staff failed to ensure routine monitoring, specific to frequency, to address Resident #1's attempts to obtain smoking materials and smoke without supervision. On 01/19/2015, Resident #1 obtained 2 cigarettes from Resident A, gained access to Resident A's lighter, attempted to light a cigarette in the absence of staff, and ignited her hair. Resident #1 was transferred to the hospital and determined to have second and/or third [MEDICAL CONDITION] the left side of the face, left side of her forehead and temple, and left side of her cheek and external ear, which required skin grafting. Resident #1 returned to the facility on [DATE], but was then found to have another cigarette on 01/24/2014, obtained from Resident A, initially without the knowledge of staff. - Resident B was assessed as safe to smoke unsupervised, but because of a 2011 incident involving Resident B using a lighter unsafely, she could not maintain cigarettes and a lighter in her possession. Nursing staff were to keep Resident B's cigarettes and light her cigarettes while smoking. However, there was no evidence of routine monitoring of Resident B by nursing staff related to her restricted access to a cigarette lighter, despite the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice specifying that the nurse provide resident monitoring. During a 01/23/2015 observation, in the absence of nursing staff to supervise, Resident B obtained a cigarette and lighter from another resident, lit the cigarette, and smoked. - Resident E was a non-smoker when admitted in June 2014. A nurse's note of 01/20/15 documented Resident E did smoke cigarettes at that time, and staff interview revealed the resident was in possession of packs of cigarettes on 01/22/2015. 12/22/2014 Smoking Assessment Questionaire assessed Resident E to require staff supervision while smoking; however, despite the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice specifying that the nurse provide resident monitoring, there was no evidence of routine nursing staff monitoring/supervision of Resident E related to smoking. 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 that Resident #1, who was assessed by the facility to require staff supervision while smoking cigarettes, obtained two (2) cigarettes and gained access to a cigarette lighter without the knowledge of staff, 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. During an interview with the DON conducted on 01/23/2015 at 10:00 a.m., when questioned regarding Resident #1 sustaining burn wounds, the DON acknowledged the 01/19/2015 incident during which Resident #1 sustained multiple burn wounds while attempting to light a cigarette using a cigarette lighter. 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 National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules revealed that the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice, Section 2.3.2(c), specified that the nurse demonstrate attentiveness and provide resident surveillance and monitoring. 1. Resident #1's 10/30/14 Admission Minimum Data Set (MDS) assessment documented diagnoses, in Section I-Active Diagnoses, including, but not limited to, Dementia and [MEDICAL CONDITION], with Section G - Functional Status documenting mobility via wheelchair and Section J - Health Conditions documenting tobacco use. A Smoking Assessment Questionaire, completed on 10/20/2014 upon Resident #1's admission, assessed the resident as requiring staff supervision while smoking. Charge Nurse AA stated, during an interview of 01/29/2014 at 10:45 a.m., that Resident #1 required staff supervision while smoking, and that Resident #1's cigarettes and lighter were to be stored locked in the medication cart. Review of Resident #1's record revealed a Nurse's Progress Notes (NPN) entry of 10/27/2014 at 4:00 p.m. which documented that (despite the need to maintain Resident #1's cigarettes and lighter locked due to her requiring staff supervision, per the 01/29/2014, 10:45 a.m. interview with Charge Nurse AA referenced above), other residents reported that Resident #1 would frequently ask them for their cigarettes. A 10/31/2014 NPN entry also documented Resident #1 continued to try to borrow cigarettes from other residents. In a 01/29/2014, 9:50 a.m. interview, the Administrator stated that, based on each resident's assessment, some residents were allowed to keep cigarettes and lighters in their possession and smoke unsupervised. As documented above, Resident #1 was assessed by the 10/20/2014 Smoking Assessment Questionaire to require supervision while smoking, and per the 01/29/2014, 10:45 a.m. interview with Charge Nurse AA, facility staff were to maintain Resident #1's cigarettes and lighter secured and supervise Resident #1 during smoking. However, even though the 10/27/2014, 4:00 p.m. and 10/31/2014 NPN entries referenced above both documented that nursing staff were aware of Resident #1's behavior of asking other residents for cigarettes (thus posing the risk of her obtaining smoking paraphernalia and smoking without staff supervision), record review revealed no evidence of licensed nursing staff providing routine monitoring, with regular frequency, to ensure that Resident #1 did not obtain cigarettes from other residents and smoke unsupervised. This was despite the standard of nursing practice, per the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice referenced above, specifying that the nurse provide resident surveillance and monitoring. Further review of Resident #1's record revealed a 01/19/2015, 3:15 p.m. NPN entry documenting that a male resident informed the nurse he had extinguished fire from Resident #1's hair, and documented the nurse observed Resident #1's hair singed and the left side of her forehead red. A 01/19/2015, 3:46 p.m. NPN entry documented that when the physician was notified of Resident #1's burns, an order for [REDACTED]. A facility investigative report (IR) dated January 22, 2015 documented the facility's investigation into the January 19, 2015 incident involving Resident #1's burns. In this IR, the facility documented that on January 19, 2015, Resident #1 and Resident #9 were in the smoking area. During facility interview, Resident #9 stated that Resident #1 showed a hand-rolled cigarette and a lighter, leaned over to light the cigarette, and accidentally lit her hair on fire. Resident #9 informed Resident C that Resident #1 was on fire, and Resident C went to smother the fire with his hands. Nursing staff assessed Resident #1 to have sustained head burns, and Resident #1 was transferred to the local hospital (where she was documented to have produced another hand-rolled cigarette) and observed with second and third [MEDICAL CONDITION] the left side of the face, third [MEDICAL CONDITION] the left side of the forehead and temple, and second [MEDICAL CONDITION] the left side of the cheek and external ear. This IR further documented Resident #1 was transferred to the Burn Center for treatment. The IR documented that it was apparent that Resident A (who was assessed as an independent smoker and was allowed to maintain smoking paraphernalia in his possession) had been the source of the hand-rolled cigarettes Resident #1 had in her possession. Resident A admitted to facility staff that he had given Resident #1 two (2) cigarettes. Further, Resident A denied giving Resident #1 a lighter, but stated that he kept 2 lighters on his dresser and that he had discovered one of the lighters missing on 01/19/2015, the incident date. Further review of Resident #1's medical record revealed a NPN entry of 01/23/2014 at 9:25 p.m. which documented she was readmitted to the nursing facility from the Burn Center on that date. This NPN entry documented Resident #1 to have skin grafts to the left ear, left scalp, and left side of the face, and that staff would continue to monitor. However, even though Resident #1 required supervised smoking for safety, as indicated by the 10/20/2014 Smoking Assessment Questionaire referenced above, and even though Resident #1 sustained second and/or third [MEDICAL CONDITION] the left side of the face, forehead/temple, cheek and external ear on 01/19/2015 while smoking unsupervised after being given a cigarette by Resident A and obtaining access to a lighter, there was no evidence to indicate that licensed nursing staff provided monitoring, at a routine frequency, to Resident #1 upon her readmission to the facility on [DATE]. This was despite the standard of nursing practice, per the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice referenced above, specifying that the nurse provide resident surveillance and monitoring. During a 02/02/2015, 12:40 p.m. interview, the DON acknowledged that prior to the 01/19/2014 incident referenced above when Resident #1 sustained multiple burn wounds while attempting to light a cigarette in the absence of staff supervision, nursing staff had provided no routine monitoring to Resident #1 regarding her smoking behaviors, other than monitoring during supervised smoking times. A 01/24/2014, 9:30 a.m. NPN entry then documented that nursing staff again found Resident #1 holding a hand-made cigarette which she stated came from another resident. This NPN entry documented that nursing staff again instructed Resident #1 to only obtain cigarettes and a lighter from staff and to smoke while being supervised. In a written statement provided by the facility, Registered Nurse (RN) EE documented that on 01/24/2014, the hand-made cigarette taken from Resident #1 had been given to her by Resident A, and that staff were instructed to closely monitor Resident #1 and Resident A for the exchange of smoking paraphernalia. However, even though Resident #1 had again obtained a cigarette without staff knowledge, per the 01/24/2015, 9:30 a.m. NPN referenced above, and even though nursing standards of practice, per the Model Nursing Administrative Rules referenced above, mandated the nurse to provide resident surveillance/monitoring, further record review continued to reveal no evidence of routine licensed nursing staff monitoring, with specific frequency, for Resident #1 related to her continued behavior of obtaining smoking materials other than smoking materials provided by facility nursing staff. Cross refer to F323, example 1, for more information regarding Resident #1. 2. Resident B's January 2015 Quarterly MDS assessment documented admission in March of 2010. Section C - Cognitive Patterns documented a Brief Interview for Mental Status (BIMS) Summary Score of 13, indicating Resident B was cognitively intact, and Section I - Active [DIAGNOSES REDACTED]. A Smoking Assessment Questionaire of 10/30/2014 documented that Resident B could smoke without supervision. During an interview on 01/23/2015 at 12:00 p.m., Resident B stated she could smoke without supervision, but could not keep her cigarettes and cigarette lighter. Resident B stated that, due to a past incident, staff kept her cigarettes and lighted her cigarettes. During an interview on 01/29/2015 at 2:20 p.m., the DON stated that Resident B was no longer allowed to keep her cigarettes and lighter due to an incident which occurred in 2011 when Resident B used her cigarette lighter to light tissue paper. The DON stated that after the 2011 incident involving Resident B's unsafe use of the cigarette lighter, nursing staff were to keep Resident B's smoking materials. Further review of Resident B's medical record revealed, however, that even though the resident was restricted from having cigarettes and a lighter in her possession, except as provided by nursing staff, due to the 2011 incident involving her unsafe use of a lighter (per the 01/29/2015, 2:20 p.m. interview with the DON referenced above), there was no evidence of ongoing monitoring of any specific frequency by licensed nursing staff of Resident B, related to her restricted access to a cigarette lighter. This was despite the standard of nursing practice, per the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice referenced above, specifying that the nurse provide resident surveillance and monitoring. During an observation of 01/23/2015 at 12:45 p.m., Resident B and Resident #3 were in the smoking area. Resident B finished smoking a cigarette provided by nursing staff, but then, even though no nursing staff were in attendance, Resident B asked Resident #3 for another cigarette. Resident #3 gave Resident B a cigarette and lighter, and Resident B lit the cigarette and began smoking, with no staff present to supervise. During the 01/29/2015, 2:20 p.m. interview referenced above, the DON acknowledged that Resident B did require nursing staff supervision while smoking, and that the resident should not have had a cigarette lighter in her possession to use without nursing staff supervision. However, the DON further acknowledged that even after the 01/23/2015, 12:45 p.m. observation referenced above during which Resident B obtained a cigarette and lighter from another resident, with no supervision, there was no system in place to ensure routine nursing staff monitoring related to Resident B's restriction to access regarding smoking materials. Cross refer to F323, example 2, for more information regarding Resident B. 3. Resident E's Admission MDS assessment of July 2014 documented facility admission in June 2014. Section I - Active [DIAGNOSES REDACTED]. Even though Resident E's Admission MDS assessment referenced above documented the resident did not smoke when admitted in June of 2014, a 01/20/2015, 10:00 a.m. NPN entry documented Resident E did smoke cigarettes. During a 01/23/2015, 10:45 a.m. interview, Resident E acknowledged that he smoked cigarettes. A Smoking Assessment Questionaire dated 12/22/2014 documented that Resident E was assessed to require staff supervision while smoking. However, further record review for Resident E revealed no evidence of licensed nursing staff monitoring of Resident E, specific to frequency, related to the resident's smoking behavior, to ensure his safety while smoking. This was despite Resident E's Smoking Assessment Questionaire assessing to require supervision while smoking, and despite the standard of nursing practice, per the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice referenced above, specifying that the nurse provide resident surveillance and monitoring. Cross refer to F323, example 3, for more information regarding Resident E. 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 02/03/2015, review of meeting minutes confirmed that the facility had met with the Resident Council to discuss the changes to the Smoking Policy, with all smokers in attendance, in accordance with Step #5 of the CAJR referenced above. - On 02/03/2015, and ongoing throughout the abbreviated survey, it was confirmed via record review that all facility residents who used tobacco products were assessed via the new Smoking Safety Evaluation Form. This was in conformance with Step #6 of the CAJR referenced above. - On 02/03/2015, and ongoing throughout the abbreviated survey, it was confirmed via record review that the facility had reviewed the Plans of Care for all residents using tobacco products, with Plan of Care additions and revisions made as needed. This was in accordance with Step #7 of the CAJR referenced above. - On 02/03/2015, Policy review confirmed the facility procedure which specified that the Interdisciplinary Care Team reassess residents who smoke on a quarterly basis, and more frequently if needed, regarding evaluation for changes in smoking abilities. Accompanying Plan of Care updates will be made. This was in accordance with Step #8 of the CAJR referenced above. - On 02/03/2015, review of the One on One Sitter Safety Log confirmed that a one-on-one si (TRUNCATED) |
2018-02-01 |