Other·December 7, 2023

F689 §483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. § 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. An unannounced visit was conducted by California Department of Public Health on 10/24/23 at 10 AM to investigate a facility reported incident regarding an allegation of patient-to-patient abuse while patients were smoking. The facility failed to implement smoking policy for Patients 1, 2, and 3 by failing to ensure: 1. Patients 1, 2, and 3 did not have a lighter and cigarette in their possession. 2. Patient 3 was supervised, and was smoking on a designated smoking area on 10/24/23. Patient 3 threw a lighted cigarette butt (end of cigarette) on the regular trash can on 10/24/2023. These failures had the potential to result in an accidental fire in the facility, which could lead to harm and injury to the Patients and staff. 1. A review of Patient 1's Admission Record indicated Patient 1 was admitted to the facility on 7/10/2023, with diagnoses of post-traumatic stress disorder (PTSD is a disorder that develops in some people who have experienced a shocking, scary, or dangerous event), nasal congestion (stuffy nose), and insomnia (inability to sleep). A review of Patient 1's Minimum Data Set (MDS, a comprehensive standardized assessment and care screening tool), dated 7/23/2023, indicated Patient 1's cognition (refers to mental abilities and processes) was intact. The MDS also indicated Patient 1 required limited assistance (highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) for dressing, toilet use and personal hygiene. Patient 1 required supervision (oversight encouragement or cueing) for bed mobility (how patient moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), transfer, walk in room and corridor, locomotion on and off unit (how patient moves to and returns from off-unit locations), and eating. A review of Patient 1's Smoking Risk Assessment (tool that is used to determine the needs of a patient who smokes), dated 10/10/2023, indicated Patient 1 smokes safely with minimal supervision. A review of Patient 1's Care Plan titled, “Risk for Injury Related to Smoking,” initiated on 7/17/2023, indicated the goal was for Patient 1 to be free from injury daily. The care plan indicated intervention was for staff to supervise Patient 1 per facility smoking policy while Patient was smoking, and to store smoking material per facility policy. 2. A review of Patient 2's Admission Record indicated Patient 2 was admitted to the facility on 4/27/2023, with diagnoses of lack of coordination, muscle weakness, and acute embolism and thrombosis of deep veins of right upper extremity. A review of Patient 2's MDS, dated 10/12/2023, indicated Patient 2's cognition was intact. The MDS also indicated Patient 2 required setup or clean-up assistance (helper sets up or cleans up; Patient 2 completes activity. Helper assists only prior to or following the activity) for eating. Patient 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as Patient completes activity. Assistance may be provided throughout the activity or intermittently) for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. Patient 2 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for shower. A review of Patient 2's Smoking Risk Assessment, dated 10/10/2023, indicated Patient 2 smokes safely with minimal supervision. A review of Patient 2's Care Plan titled, “Risk for injury Related to Smoking,” initiated on 6/12/2023, indicated the goal was for Patient 2 to be free from injury daily. The care plan indicated interventions were for staff to supervise Patient 2 per facility smoking policy while Patient is smoking, and to explain facility smoking policy to patient and family. During an interview on 10/24/2023 at 3:30 PM, Patient 2 stated, she keeps her lighter and cigarettes with her. 3. A review of Patient 3's Admission Record indicated Patient 3 was admitted to the facility on 4/12/2022 with diagnoses of difficulty in walking, muscle weakness, and hypertension (high blood pressure). A review of Patient 3's MDS, dated 7/27/2023, indicated Patient 3's cognition was intact. The MDS also indicated Patient 3 required limited assistance for dressing, toilet use and personal hygiene. Patient 3 required supervision for bed mobility, transfer, walk in room, walk in corridor, locomotion on and off unit and eating. A review of Patient 3's Smoking Risk Assessment, dated 10/23/2023, indicated Patient 3 has the ability to use ashtray to self-extinguish cigarette and manage ashes, and that Patient 3 smokes safely with minimal supervision. A review of Patient 3's Care Plan titled, “Risk for injury Related to Smoking,” initiated on 7/17/2023, with revision date of 7/24/2023, indicated the goal was for Patient 3 to be free from injury daily. The care plan indicated intervention for staff to supervise Patient 3 while smoking, store smoking material per facility policy (location: locked storage cabinet), and to follow smoking schedule. During an interview on 10/24/2023 at 11:53 AM, Patient 1 stated that she had always kept her lighter in her possession. During an observation in Patient 3's room and interview on 10/24/2023 at 12:50 PM, Patient 3 was awake and lying in bed. Patient 3 stated that he keeps his lighter and cigarettes with him. Patient 3 presented a box of cigarettes and blue colored lighter, which he pulled from his bedside drawer. During a concurrent observation in the facility's outdoor garden and interview on 10/24/2023 at 1:15 PM with the Director of Nursing (DON), the DON verified Patient 3 was observed smoking without staff supervision at the facility’s outdoor garden. The DON stated the facility’s outdoor garden was a non- designated smoking area. During an observation in the facility garden on 10/24/2023 at 3:50 PM, Patient 3 was observed smoking outside the designated smoking area without supervision, and during unscheduled smoking time. Patient 3 was observed throwing his cigarette butt on the regular trash can. During an interview on 10/24/2023 at 4PM with Certified Nursing Assistant 1 (CNA 1), CNA 1 verified a cigarette butt was thrown in the regular trash can. CNA 1 stated, cigarettes should only be thrown in the designated ash tray to avoid accidents that could lead to a fire. CNA 1 stated the patients who smoke should always be supervised by a staff to remind them to stay in designated smoking area while smoking and to use the ashtrays located in the designated smoking area. During a concurrent observation in the activity room and interview on 10/24/2023 at 3:20 PM with activity assistant (AA), AA stated, Patients 1, 2, and 3's smoking paraphernalia were not kept in the designated locked storage cabinet. During a concurrent interview and record review on 10/25/23, at 11 AM, MDS nurse stated that Patients 1, 2, and 3 are smokers. MDS nurse stated Patients 1, 2, and 3’s care plan interventions related to smoking indicated supervision while smoking and smoking material should be stored per facility policy. The MDS nurse stated, these interventions were not being followed because Patients 1, 2, and 3 go out and smoke whenever they want and have the cigarette and lighter in their possession. The MDS Nurse stated the facility staff should supervise the Patients while smoking and should keep the smoking materials in the designated locked storage cabinet to ensure safety of patients in the facility. During a concurrent observation in the smoking patio and interview with the Activity Director (AD) on 10/25/23 at 1:45 PM, AD stated Patients 1, 2, and 3 are independent and comes out anytime they want to smoke. AD stated, scheduled supervised smoking times are from 10 AM to 10:30 AM, 1 PM to 1:30 PM, 6PM to 6:30 PM and 8 PM to 8:30 PM. AD stated Patients 1, 2, and 3's smoking materials are not being kept in the activity room’s designated locked cabinet. AD stated that cigarettes are to be thrown in the designated receptacles with ashtrays in the designated smoking area. A review of the facility`s undated Policy titled, "Smoking Policy and Guideline," indicated that all Patients would need staff supervision and must smoke only at supervised smoking times. Supervised smoking times will be posted and are also listed below: Supervised Smoking Times 10:00 A.M. -10:30 A.M. 1:00 P.M. -1:30 P.M. 6:00 P.M. - 6:30 P.M 8:00 P.M. -8:30 P.M. The facility's Smoking Policy and guidelines also indicated staff determines safety risks related to smoking. Patients are: 1. Not allowed to keep cigarettes, matches, or lighters in your possession. 2. Only be allowed to smoke at the supervised smoking times under staff supervision The facility failed to implement smoking policy for Patients 1, 2, and 3 by failing to ensure: a. Patients 1, 2 and 3 did not have a lighter and cigarette in their possession. b. Patient 3 was observed smoking outside the designated smoking area without staff supervision and threw a lighted cigarette butt (end of cigarette) on the regular trash can on 10/24/2023. These failures had the potential to result in an accidental fire in the facility, which could lead to harm and injury to the Patients and staff. The above violation had a direct or immediate relationship to the health, safety, or security of Patients 1, 2, and 3.