Accidents, including fires and skin injury, caused by cigarettes are a serious danger to residents in long-term care (LTC) facilities. Indeed, residents who are identified as “smokers” and who are permitted to smoke can present safety and compliance issues for the resident, other residents, and the facility.

All facilities that permit smoking should have a policy that specifies, among other information, a designated smoking area and the need for smokers to strictly abide by the facility's rules. In addition, visitors should be well-informed of the facility's smoking policy.

This article sets forth documentation guidelines by recommending a facility smoking policy, initial and quarterly smoking assessments, a smoking agreement between the facility and the resident, and suggestions for patient care planning documentation for residents who smoke. The clinical record for each resident who smokes should include, at a minimum, the following documentation:

Initial assessment

The current Federal Guidelines for LTC Settings §483.25(h)(1)(2), available at https://www.iadvanceseniorcare.com/CMSHazardGuidelines, clearly indicate the need to “ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision….” Specific documentation will assist the facility and the staff in ensuring that this requirement is met.

Facilities that permit smoking should utilize a Smoking Assessment form. The above-cited guideline at F323 also addresses the need to assess “…the resident's capabilities and deficits [to] determine whether or not supervision is required…” The Initial Smoking Assessment should assess the resident's cognitive and physical abilities. For example, the assessment should answer at least the following questions:

• Is the resident physically capable of lighting and extinguishing his/her own cigarette without assistance?

• Is the resident able (both cognitively and physically) to extinguish a lit cigarette ash or lit cigarette which has fallen on the resident and/or on others?

• Does the resident require assistance to the designated smoking area?

• Does the resident have any physical diagnoses which could affect smoking ability, such as syncope, arthritis, paralysis, etc.? Does the resident use oxygen?

The main purpose of the Initial Smoking Assessment is to determine: (1) if the resident is able to comprehend and comply with the facility's smoking policy; (2) if the resident will be required to be supervised or unsupervised while smoking; and (3) if the resident will be required to wear a smoking apron.

The Smoking Agreement

Once the initial Smoking Assessment is completed, the interdisciplinary team should specify, as part of a Smoking Agreement, under what restrictions, if any, the resident may smoke. The Smoking Agreement should include the following statements:

• A statement that a copy of the facility's smoking policy has been provided to the resident and that the resident understands the policy and agrees to abide by it.

• A statement concerning whether the resident will require a smoking apron, and whether the resident will require supervision while smoking.

• A statement that the resident understands that smoking by residents when oxygen is in use is prohibited.

• A statement indicating where the smoking materials are to be kept (e.g., at the nursing station).

• A statement indicating the location of the designated smoking area and that the resident agrees to smoke only there. If the facility has a designated smoking time, this should also be specified in the agreement.

• A statement that the resident agrees not to share smoking materials or cigarettes with any other resident.

• A statement that the resident understands that refusal to abide by the smoking agreement could result in discharge from the facility.

The form is signed and dated by both the individual completing the information on the form (usually a preprinted form) and, of course, includes the resident's signature and date. The original of the Smoking Agreement is filed in the clinical record and a copy is provided to the resident.

Care plan documentation

Federal Guideline 42 CFR 483.25(H)(1) and (2) also requires that the care plan for residents who require supervision when smoking reflects specific information and that the resident's plan of care be reviewed and revised periodically as needed.

The care plan for a resident who smokes should include, at a minimum, the following:

A Problem Statement that reflects the potential for smoking-related injury related to: (specify type of impairments).

A Goal Statement that includes a statement that the resident will be compliant with the Smoking Agreement and be free from smoking-related injuries on a daily basis.

Approaches that should reflect those areas in which staff will ensure that the resident and other residents will be free from smoking-related injuries such as:

• a smoking apron

• supervision

• monitoring to ensure that smoking is confined to the designated area

• proper storage of the resident's smoking materials

• need for initial and quarterly Smoking Assessments

Care plan approaches should also include a statement that if the resident is not compliant with the Smoking Agreement, the resident will be reevaluated immediately.

Quarterly smoking reassessment

A quarterly smoking reassessment is done for all residents who smoke. This is done at the time of the quarterly care plan reviews. If there has been a significant change in the resident's condition or in the resident's compliance with the smoking agreement, the smoking reassessment is done at this time, rather than waiting for a quarterly review.

The Quarterly Smoking Reassessment determines whether the resident has been compliant with the Smoking Agreement for the past quarter, and whether there have been any changes in the resident's physical or cognitive abilities. If there have been any changes and/or refusal of the resident to abide by the Smoking Agreement, an initial reassessment is done.

MDS relating to a resident's smoking ability

Staff should ensure that the initial and quarterly Smoking Assessment findings correlate with specific sections of the MDS including:

• Section B4—Cognitive Skills for Daily Decision Making

• Section Bf—Indicators of delirium (periodic disordered thinking/awareness)

• Section I1—Diagnosis

• Section O(4)(a)—Use of antipsychotic medications

• Section P1(g)—Oxygen Therapy

Conclusion

Residents who are permitted to smoke in LTC facilities can present safety and compliance issues for everyone in the facility. Residents who smoke require specific documentation in their charts, which will help to ensure that the facility follows federal, state and Life Safety Codes, and guidelines related to avoiding accidents. Proper documentation also assists staff in determining the specific needs of the smoking resident.