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Based on observations, interviews, review of medical record and incident documentation for 1 of 1 patient (Patient 3), review of fire incident and safety documentation, and review of policies and procedures it was determined that the hospital failed to ensure the provision of care in a safe environment for all patients receiving oxygen.

Findings include:

During interview with the COO and CNO on 06/08/2023 beginning at 0955 they stated that on 06/01/2023 at ~ 1800 a pediatric patient, Patient 3, on an inpatient unit sustained burns on their face, shoulder, and chest when a fire erupted on the patient's nasal cannula used to administer oxygen. They stated the incident was unwitnessed by staff and occurred while the patient's parent and siblings were in the patient's room. Staff responded when they heard screams coming from the room. They stated that the parent reported that their cigarette lighter ignited as they hugged the patient goodbye before they exited the room. The COO stated that the AOC on call, who was the CNO, was notified of the incident between 1830 and 1900, and a "safety stop" response process was initiated. The patient was treated for burns and was transferred to another hospital for specialty burn care.

Review of "safety stop" and incident documentation reflected that staff initiated actions to address the fire incident and the patient's burns immediately, a formal investigation was initiated that was continuing on the day of this survey, and corrective actions to improve communications regarding oxygen safety and fire response were being implemented.

Refer to the findings cited at Tag A-709 under CFR 482.41(b), Standard: Life Safety from Fire.

Based on observations, interviews, review of fire incident and safety documentation, and review of policies and procedures it was determined that the hospital failed to comply with the Life Safety From Fire requirements related to:
* Evacuation and Relocation Plan
* Fire Drills
* Gas Equipment - Respiratory Therapy Sources

Findings include:

1. Refer to the findings cited at Tags K-711, K-712, and K-925 on the attached Life Safety from Fire CMS 2567 SOD report for Building-01, the main hospital.