Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0741
Based on observation and interview it was determined that the facility failed to provide a metal, self closing, self extinguishing container, to empty ashtrays into, in one of two smoking areas.
Observation on September 17, 2019, at 11:55 a.m., revealed the designated employee smoking area lacked a metal, self closing, self extinguishing container, to empty smoking materials into prior to disposal.
Interview with the maintenance supervisor and the administrator on September 17, 2019, at 11:55 a.m., confirmed the designated employee smoking area lacked a metal, self closing, self extinguishing container, to empty smoking materials into prior to disposal.
| ||Plan of Correction - To be completed: 10/17/2019|
No adverse affects occurred from the employee designated smoking area lacking a metal, self-closing, self-extinguishing container to empty smoking material in prior to disposal.
Edison Manor will provide education to the Maintenance supervisor, the facility has purchased the proper metal, self-closing, self-extinguishing container.
The Administrator or designee will be responsible for ongoing compliance to ensure safe disposal of cigarette butts. Audits will be completed 5 times a week for two weeks, weekly for two weeks, and monthly for two months. Results of the audits will be reported to the Quality Assurance Performance Improvement committee monthly for two months then as directed by the QAPI committee.