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Based on record review, interview with patients and staff, review of the facility's policies and procedures and the Patient Handbook given to patients on admission, it was determined the facility failed to ensure all the patients were notified of when smoking privileges would be restricted. This had the potential to effect all patients who smoked.

Findings include:

The Psychiatric Units Patient Handbook

page 7: Smoking

"The hospital is a non-smoking facility. All patient use of tobacco products will be assessed upon admission. Patients may be allowed to smoke outside if a safe area is available, if clinically appropriate and if by the physician. For patients who are unable to leave the unit, a Nicoderm patch or Nicorette gum may be ordered by the physician to assist with refraining from the use of tobacco products during their hospitalization until clinically able to leave the unit."

1. Medical record (MR) # 396703 was admitted to the facility on 12/22/09 with a diagnosis of Bipolar Schizophrenia. Review of the nurse's documentation on 12/28/09 and 1/1/10 at 09:00 revealed the patient had gone outside to smoke with staff and peers.

Review of the patient's Medication Administration Records revealed the patient refused his/her psychotropic drugs on 12/23/09 AM, 12/24/09 AM and PM, 12/25/09 AM, 12/26/09 AM, 12/27/09 AM, 12/28/09 PM, 12/29/09 AM and PM, 12/30/09 AM and PM, 1/1/10 AM and PM, and 1/2/10 AM and PM.

Review of the nurse's documentation on 1/2/10 at 09:00 revealed the client had been noncompliant with medication regime since his/her admission to the unit.


Review of the nurse's documentation on 1/2/10 at 18:45 revealed the patient's privileges were restricted that day because the patient refused his/her AM medication.

Review of the physician's orders from 12/22/09 to 1/5/10 revealed no documentation of an order to restrict the patient's privileges.

An interview was conducted with the Nurse Manager of Behavioral Health on 1/7/10 at 8:45 AM. The surveyor asked the Nurse Manager of Behavioral Health to explain the process for restricting smoking privileges from a patient. The response was if a patient became aggressive, severely agitated or loss of control, then the smoking privileges would have to be restricted to closely observe the patient. If a patient refused to participate in group or refused medication that would not be a reason to restrict privileges. The surveyor then asked about the docuimentation dated 1/2/10 at 18: 45. The response was the patient's privileges should not have been restricted.

The surveyor asked the Nurse Manager of Behavioral Health on 1/7/10 at 9:30 AM, where it was written the patients were informed of the actions that would lead to having the patient's smoking privileges restricted. The response was the patients were not given any type of statement concerning patient's privileges and when they could be restricted.