Other·June 28, 2023

California Code of Regulations Title 22, Section 72311 Nursing Services - General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, section 72523 - Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. California Code of Regulations, Title 22, section 72507 - Smoking (b) The facility shall provide designated areas for smoking. Patients shall be permitted to smoke only in designated areas. The designated area shall be under the periodic observation of facility personnel or responsible adults. This does not preclude the designation of the patient rooms as smoking areas. Title 42 CFR 483.25(d) Accidents. The facility must ensure that - 483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and 483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. On May 9, 2023, at 10 a.m., an unannounced visit was conducted at the facility to investigate a quality-of-care issue. It was determined based on observation, interview, and record review, the facility failed to ensure a system was in place to ensure supervision was provided for Patient 3 during smoking activities. The facility disclosed being a non-smoking facility; however, had allowed patients to smoke cigarettes unsupervised while at the facility. The facility smoking policy did not provide information ensuring safe smoking procedures. These failures of the facility resulted in Patient 3 sustaining burn on her nose while smoking without supervision. On May 9, 2023, at 11:23 a.m., during an observation and concurrent interview with Patient 3, she was observed outside of the facility in her wheelchair smoking a cigarette unsupervised. Patient 3 stated she burned her nose lighting a cigarette while she was smoking outside a few days ago. She stated that she would go out to smoke when she wanted to and kept a lighter with her. Patient 3 stated that she has her lighter and was observed pulling it out of her pocket. A review of Patient 3's records indicated the patient was admitted to the facility on September 8, 2017, with diagnoses that included Type 2 diabetes mellitus (disease in which the blood glucose, or blood sugar, levels are too high), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and chronic pain. A review of Patient 3's "Safe Smoking Assessment," dated August 10, 2021, indicated, "The Patient can light and smoke a cigarette or other smoking device while demonstrating a safe technique for putting out the matches or lighter and disposing of ash...IDT (Interdisciplinary Team) Determination, Safe Smoker..." A review of Patient 3's care plan initiated on March 15, 2022, and revised on July 25, 2022, indicated: "Focus: The resident (Patient 3) is a smoker... Goal: The resident (Patient 3) will not suffer injury from unsafe smoking practices...The resident (Patient 3) will not smoke without supervision... Plan/Intervention: Instruct resident (Patient 3) about smoking risks and hazards and about smoking cessation...Instruct resident (Patient 3) about the facility policy on smoking locations, time, and safety concerns..." A review of Patient 3's "Progress notes," written by Licensed Vocational Nurse (LVN) 1, on May 2, 2023, indicated, "Patient has a burn on her nose, I asked patient what happened, patient stated over the weekend she burned herself with an electric lighter, trying to light a cigarette...Explained to patient that she is not to have a lighter or cigarettes on her person as our policy states there is smoking times and activities will go out with patient and they hold the cigarettes and lighter and she must obey the rules of our facility, patient stated she understands and will not happen again..." A review of Patient 3's record did not indicate a care plan was developed to address the incident when the patient sustained a burn injury on her nose on May 2, 2023. A review of Patient 3's "Progress notes," written by the Social Services Director (SSD 2), on May 2, 2023, at 12:47 p.m., indicated, "Went to Patient's room to discuss the new smoking policy (Refers to the undated Smoking policy and procedure effective prior to May 9, 2023). Noticed a small mark on her nose and asked how she got it. She stated that she borrowed a lighter from a Nurse and had burned it while lighting her cigarette. Charge Nurse informed and our treatment Nurse came in to see Patient while this writer was still in the room. Inservice regarding our smoking policy was reviewed with Patient." On May 9, 2023, at 11:15 a.m., during an interview with Licensed Vocational Nurse (LVN 1), she stated there was a "guy" who used to oversee the patients during smoking, but she had not seen that person and currently she did not know who was supervising the patients while they smoke. On May 9, 2023, at 2:30 p.m., the Director of Nursing (DON) was interviewed. The DON stated the facility had always allowed patients to smoke unsupervised since she started working at the facility. On May 9, 2023, at 7:18 p.m., during a concurrent interview and review of the undated facility smoking policy titled, " Smoking Policy and Procedure," with the Administrator (ADM); he stated patients should be supervised during smoking. He stated the facility had a fire extinguisher, smoking blankets, and smokeless ashtrays but he was not sure if the facility had any aprons. He further stated the cigarettes and lighters should be locked away when not in use. The ADM reviewed the undated facility smoking policy indicating the facility was a non-smoking facility for patients and he stated the policy was not current. The ADM stated he was aware of Patient 3's burn from smoking and he stated Patient 3 should not have her lighter on her person. A review of the facility policy and procedure titled "Smoking Policy and Procedure" undated, indicated, "This facility is a NON-SMOKING facility for Patients and Patients MAY NOT carry any type of smoking materials..." It was determined based on observation, interview, and record review, the facility failed to ensure a system was in place to ensure supervision was provided for Patient 3 during smoking activities. The facility disclosed being a non-smoking facility; however, had allowed patients to smoke cigarettes unsupervised while at the facility. The facility smoking policy did not provide information ensuring safe smoking procedures. These failures resulted in Patient 3 sustaining burn on her nose while smoking without supervision. This violation had a direct or immediate relationship to the health, safety, or security of the patients.