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Based on interview, record review, and review of facility policy it was determined the facility failed to ensure that three (3) of ten (10) sampled patients (Patients #1, #4, and #5) received information regarding their rights related to the facility's tobacco use policy. According to staff interviews, patients were not permitted to leave the medical floor to go outside and smoke, and if the patient did not comply the patient would be discharged. Review of the facility's tobacco use policy revealed the policy did not specify that patients who were noncompliant with the tobacco use policy would be discharged. In addition, the policy was unclear regarding designated smoking areas. On 06/22/15, staff observed Patient #1 leave the medical floor by way of the elevator and smoke in the facility parking lot. Patient #1 was discharged on 06/23/15 for noncompliance with the facility's tobacco use policy. As a result of the discharge, Patient #1 waited outside the facility in 90-degree weather for approximately four (4) hours for transportation with no access to his/her oxygen therapy. There was no evidence that Patient #1 had been informed of the facility's rules of discharge related to tobacco use, and no evidence that Patient #1 ever received a medical exam and/or was informed about health status. During the course of the investigation, interviews were conducted with Patients #4 and #5, and both patients stated they had not received information informing them they would be discharged if they were noncompliant with the facility's tobacco use policy.

The findings include:

Review of the facility policy titled "Tobacco Use," revealed the facility had developed a policy regarding tobacco use. According to the policy, designated tobacco use areas were located outside the facilities, away from the entrance, and were identified with signs. However, the policy went on to say locally designated tobacco-free campuses did not have areas for such tobacco use. The policy/procedure for violations revealed if an employee or visitor was observed using tobacco in a tobacco-free area, they would be reminded of the tobacco-free policy and if the guest or employee disregarded the policy, Management or Security would be contacted. The policy did not address violations for patients who disregarded the policy.

Review of the facility's "Patient Rights & Responsibilities," issued to the patients upon admission revealed the patient's rights and responsibilities included the right to receive considerate, respectful, and compassionate care with dignity and comfort, including consideration of personal time, values, and beliefs. The patient rights also included the right to be informed about health status, treatment, and results of care, including unanticipated outcomes, and what to expect with their illness in terms they could understand.

1. Medical record review revealed the facility admitted Patient #1 on 06/22/15 at 6:35 PM as a direct admission from the physician's office. Review of the nursing assessment revealed staff identified Patient #1 had smoked for approximately 42 years with no desire to stop smoking. Further review revealed the patient did not receive a nicotine patch (per routine orders) until 12:30 AM on the morning of 06/23/15 and at 7:35 AM Nursing signed off on the physician order to discharge Patient #1 due to noncompliance with the facility's smoking policy. There was no evidence that Patient #1 was informed of his/her health care status, treatment, and results of care as documented in the patient rights and responsibilities issued to the patient upon admission.

A telephone interview was conducted with the complainant on 06/30/15 at 10:15 AM who stated Patient #1 was "kicked out" of the hospital for smoking and "made to go outside" by the House Supervisor in high temperature weather until transportation arrived. The complainant stated Patient #1 requested to stay in his/her room until transportation arrived but the request was denied. The complainant stated Patient #1 was on continuous oxygen at home and had no access to oxygen after being discharged from the facility. The complainant stated Patient #1 went through the lobby of the hospital to the Emergency Department triage area to request a cup of ice and asked if staff could check the patient's oxygen saturation. According to the complainant, the Emergency Room staff offered to see the patient but Patient #1 refused to be seen in the Emergency Room. The complainant stated, "If smoking was the issue, why didn't they offer a nicotine patch upon admission?" The complainant was aware that smoking was not permitted inside the hospital. However, the complainant further stated at no time did staff say the patient would be "put out" if caught smoking at the facility. According to the complainant, it was suspected that Patient #1 smoked in an empty room down the hallway from the patient's room however, no one witnessed the patient smoking.

Interview with the attending physician on 06/30/15 at 2:00 PM revealed it was hospital policy to discharge patients who were noncompliant with the smoking policy. The attending Physician stated, "It's not my rule." The attending physician stated the physicians were told by Administration to discharge patients who were caught smoking. According to the attending physician, it was a danger to other patients if a patient was caught smoking in/around oxygen. The attending physician stated, "Nurses normally use the standard nicotine patch on the routine orders." The attending physician stated he was not aware Patient #1 was not offered a nicotine patch upon admission. The attending physician gave no explanation why Patient #1 was not medically screened prior to discharge.

The Admission Nurse stated in interview on 07/01/15 at 2:30 PM that patients normally requested the nurse call the physician for an order to apply nicotine patches. According to the Admission Nurse, Patient #1 reported having smoked over a pack of cigarettes daily for approximately 42 years. The Admission Nurse stated, "If they want us to apply nicotine patches on admission they need to add the routine order to the admission packet." The Admission Nurse did not recall offering Patient #1 a nicotine patch. The Admission Nurse stated it was facility policy to not allow smoking on campus. The Admission Nurse was not aware if the facility policy had been changed since the campus went non-smoking. The Admission Nurse stated she normally worked in the Intensive Care Unit (ICU) and did not deal with patients who left the unit to smoke.

2. Medical record review for Patient #4 revealed the patient was identified to be a smoker at the time of admission and the resident had no desire to stop smoking.

Interview conducted with Patient #4 on 06/30/15 at 5:30 PM revealed the patient did not receive information upon admission that informed the patient that they would be discharged if they did not follow the smoking policy. Patient #4 further stated he/she was not offered a nicotine patch.

3. Medical record review for Patient #5 revealed the patient was identified as a smoker at the time of admission and the resident had no desire to stop smoking.

Interview conducted with Patient #5 on 06/30/15 at 5:40 PM revealed the patient did not receive information upon admission that informed the patient that he/she would be discharged if he/she did not follow the smoking policy. Patient #5 further stated that he/she was not offered a nicotine patch.

Interviews conducted with Licensed Practical Nurse (LPN) #1 on 06/30/15 at 4:50 PM, Registered Nurse (RN) #5 on 06/30/15 at 5:00 PM, LPN #2 on 06/30/15 at 5:20 PM, and RN #4 on 06/30/15 at 5:10 PM, revealed nicotine patches were available only if patients requested the nicotine patch.

Based on interview, record review, and policy review it was determined the facility failed to ensure patients were given the opportunity to participate in the planning and implementation of the plan of care for three (3) of ten (10) sampled patients (Patients #1, #4, and #5) who were identified to be smokers with no desire to stop smoking. On 06/23/15, the facility discharged Patient #1 for noncompliance with the facility's smoking policy with no evidence that the facility developed/implemented a plan regarding Patient #1's history of smoking and no evidence the patient was offered the opportunity to participate in the care planning opportunity. Furthermore, interviews during a tour of the medical surgical floor on 06/30/15 between the hours of 3:00 PM and 6:00 PM revealed Patients #4 and #5 had not been included in the development and implementation of his/her plan of care regarding smoking.

The findings include:

1. Review of facility policy titled "Adult and Pediatric Admission Assessment," revealed the facility had a system in place for the interdisciplinary plan of care for the learning needs of the patients. According to the policy, the Registered Nurse (RN) was to initiate the plan of care after completing the initial assessment and identify the patient's needs/problems. Further review of the policy revealed the identified patient needs/problems were followed by measurable outcomes. In summary the policy's interdisciplinary approach was to benefit both the patient and staff and the process was to appreciate the patient as an integrated whole.

Review of the facility's Patient Rights and Responsibilities issued to the patients upon admission revealed the patient's rights included the right to participate in the development and implementation of the patient's plan of care, and to make decisions regarding care.

Medical record review revealed the facility admitted Patient #1 on 06/22/15 at 6:35 PM as a direct admission from the physician's office. Review of the nursing assessment revealed staff identified Patient #1 had smoked for approximately 42 years and had no desire to stop smoking. There was no evidence Patient #1 was given the opportunity to participate in the development and implementation of a plan to address the patient's smoking history. Patient #1's care plan addressed ineffective breathing pattern and routine physician orders were available for nicotine replacement therapy upon admission. However, the nicotine replacement was not offered until 06/23/15 at 12:30 AM.

The Admission Nurse stated in interview on 07/01/15 at 2:30 PM that she started Patient #1's admission but did not complete the admission because it was at the end of her shift. The Admission Nurse was not aware if Patient #1 was offered the opportunity to participate in the care planning.

Interview with the House Supervisor on 06/30/15 at 11:00 AM revealed Patient #1 was discharged on 06/23/15 after the patient was caught smoking against facility policy. The House Supervisor gave no explanation why Patient #1 was not offered the opportunity to participate in the development/implementation of a plan to address the patient's smoking issues.

2. Review of the medical record for Patient #4 revealed the patient was identified to be a smoker at the time of admission and had no desire to stop smoking. There was no evidence in the record of a plan of care to address smoking or that the patient was offered the opportunity to participate in the plan of care.

Interview conducted with Patient #4 on 06/30/15 at 5:30 PM revealed staff had not discussed a plan for smoking with the patient, nor was the patient offered an opportunity to participate in planning.

3. Review of the medical record for Patient #5 revealed the patient was identified to be a smoker at the time of admission and had no desire to stop smoking. There was no evidence in the record of a plan of care to address smoking or that the patient was offered the opportunity to participate in the plan of care.

Interview conducted with Patient #5 on 06/30/15 at 5:40 PM revealed staff had not discussed a plan for smoking with the patient, nor was the patient offered an opportunity to participate in planning.

Interviews conducted with Licensed Practical Nurse (LPN) #1 on 06/30/15 at 4:50 PM, Registered Nurse (RN) #5 on 06/30/15 at 5:00 PM, LPN #2 on 06/30/15 at 5:20 PM, and RN #4 on 06/30/15 at 5:10 PM, revealed staff was not aware of any interdisciplinary health care team working with patients regarding smoking issues.