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Based on staff interviews, review of policies and procedures, medical records, and observation of hospital physical environment, it was determined that the hospital failed to provide care in a safe setting resulting in fire in the patient's room and his death.

As indicated in A0144, on November 8, 2013 at 2240 (10:40 PM), the Baltimore City Fire Department report revealed that a 62 year old patient died as result of a fire and was found deceased in his hospital bed. The survey revealed concerns with the assessment and management of patients identified as smokers in a smoke and tobacco free hospital.

Based on a review of the hospital grievance policy, it is determined that policy has no provision for informing a complainant of investigations, which continue past seven (7) days in length.

Hospital policy " Patient Complaints and Grievance Management " (revised 7/13) states in part, " A written response regarding resolution of the grievance is provided in 7 days to the complainant. If the grievance is not resolved in 7 days, the complainant receives a written response in 21 days with final resolution of grievance. " This policy statement does not include communication with the complainant related to resolution timelines, and therefore, does not meet regulation.

Based on a reviewof the reords of outpatient # 6, and two inpatient records #7 and #8 and hospital policies , it is determined that these 3 patients received no assessment of advance directive status prior to care.

Hospital policy " Advance Medical Directives " (revised 12/12) reveals in part, " This policy applies to any adult patient receiving care at (name of hospital) or any affiliated clinics, " and " B(a) The nurse or ancillary patient care staff performing initial assessment/intake triage screens for the presence of Advance Medical Directive and documents patient response. "

Patient #6 registered with the outpatient radiology/oncology clinic. A review of the record revealed no evidence that patient #1 was queried regarding an advance directive. This part of the intake assessment was left "blank', despite the facxt that patient #1 had already received treatment.

Patient #7 was admitted to the labor and delivery unit for a caesarean section. Under the advance directive portion of the patient record are preprinted boxes which may be electronically checked. The box checked for patient #7 states " Not applicable/out-patient procedure."

Patient #8 was admitted to the same unit while in labor. Review of patient #8's record also reveals the statement, " Not applicable/out-patient procedure. " While hospital staff is aware that advance directive attributions to the records of patient #7and #8 are incorrect, they were unable to explain them. Additionally, while labor and delivery are inpatient units, staff acknowledged that they know that advance directives are applicable for out-patient procedures.

Based on staff interviews, review of policies and procedures, medical record review for patient #1, and observation of hospital physical environment, it was determined that the hospital failed to provide care in a safe setting for patient #1 who was a paraplegic requiring care for bone infection and failed to insure that emergency code carts were checked as required.

Patient #1 is a 62 year old patient who was admitted to the hospital on 11/1/13. Patient #1 medical history is significant for gunshot wound to the back, leaving the patient paraplegic, bone infection status post six weeks antibiotics stopped on 7/26/13. The patient had stage IV sacral ulcer and bilateral heels wounds. The patient stated the wounds were worse. The patient also had history of anemia and signs of infection. He was transferred from an outside hospital for further management by plastic surgery.

The investigation of the complaint revealed that patient #1 was identified during the triage intake as a current some day smoker. There was no further assessment to determine what the patient smoked, how much, how often, and did he experience any symptoms when he could not smoke. This information would have helped the hospital to determine the patient's potential risk for smoking. There's no indication that the patient was questioned if he had cigarettes and lighter or if he was offered nicotine replacement therapy.

Per patient #1's medical record, on 11/4/13 at 2:00 AM the nurse documented that patient #1 refused "to roll over, charge nurse called for assistance, patient got agitated and defensive, grabbed knife from bedside table and seemed to be threatening nurses. Said "they are trying to kill me," patient redirected unsuccessfully. Security was called to remove the knife. Dressing was only partially changed. Patient has cigarettes in room and ashes were noted in water cup. Med ID came to talk with patient. At 7:30 AM the nurse documented that she received report from night RN, patient seen and ID verified at bedside report. Cigarette smell present in room, patient stated "I started to smoke but put it out." RN informed patient that smoking is absolutely not allowed in the room and if event happened again that security will be called. Dr. S. present at this time when patient informed of policy on smoking. On the same day at 7:03 AM the physician documented "this morning he was also smoking in his room, this is the second time he has done this."

The patient was referred for psychiatric consult before returning to his long-term care facility for prior behavior and thoughts someone wanted to kill him. The psychiatric consult was completed on 11/4/13 at 11:00 AM. The patient reported difficulty with memory and mood over the past 5-6 months but attributes it to concerns regarding his daughter. The patient had pulled a knife on a nurse at an outside hospital and again at University of Maryland Medical Center. Acknowledged that he's not himself and thought people were trying to harm him. He denied wanting to harm himself or anyone else. The patient was thought to have delayed recall, abstractive thinking, impaired language and attention. His Axis I diagnosis was cognitive impairment NOS (not otherwise specified). Problem #1 pulling knife related to feeling fearful and poor impulse control and evidence of paranoia. It was recommended that he receive careful oversight of medications and mental health follow-up on return to the LTC (long term care) facility. His second identified problem was significant cognitive impairment related to progressive dementia and/or delirium. Recommendations included neuro-cognitive evaluation and testing for treating causes of delirium and dementia on return to LTC facility. Other care recommendations were included.

Based on interview with nursing staff, the investigation of the complaint, and medical record review revealed the hospital did not maintain a safe environment of care for patient #1 as evident by the following concerns:

1. Patient #1 was identified as a smoker but no risk assessment for smoking performed.
2. Patient #1 was bedfast due to paraplegia.
3. Patient #1 had evidence of smoking in his room on two occasions.
4. Patient #1 was not searched after evidence of smoking in his room.
5. Beyond the psychiatric consult there was no change in the plan of care for patient #1. He was allowed to keep his cigarettes, he was not offered a nicotine patch, there was no change to his plan of care and no documentation of any smoke cessation education and counseling beyond one nurse's note.
6. The interventions reportedly taken by staff were not documented in the medical record. For example, it was stated that the patient was counseled, which was documented but the offering of the nicotine patch and the patient's refusal was not documented. The patient also did not have an order for a nicotine patch.
7. The Tobacco Free policy revised in December 2012 did not address a thorough assessment process or management of the non-compliant patient.
8. Also, it appears that the psychiatric consult was not factored into the patient's plan of care or whether it would affect his ability to be compliant with the tobacco free policy.
9. There was no documentation that the patient's smoking in his room was reported to the security staff per the hospital policy.
10. Although the physician was aware of the patient smoking in his room, there was no order for nicotine replacement therapy, no documentation regarding patient risk or plans to address the behavior.

Although the unit involved was not equipped with an automatic sprinkler system, there was no evidence of the management of patients who choose to smoke in a smoke free facility. The hospital is a smoke free facility and at the time of the fire had a Tobacco Free policy and procedure last revised in December 2012. The policy included objectives, indications for use, definitions, responsibility, and procedure. As previously noted, the nursing triage intake only asked whether the patient is a smoker. The policy failed to outline the process to address and manage a patient who was non-compliant with the tobacco free policy. Once the patient was identified as a smoker, the staff failed to develop a plan of care to deal with the patient's risky behavior as evident by the patient being caught twice by staff smoking in his room. The failure to address the patient's behavior not only placed the patient at risk but other patients as well. The failure to assess and manage the patient's risky behavior of smoking in his room ultimately led to a fire and the patient's death.

The Tobacco Free policy was reviewed and it was noted that the policy was revised on December 2013. Under definitions it included the symptoms of nicotine withdrawal and under nursing responsibility included the completion of an event report for patient non-compliance. Under the procedure there is a process for assessment and management of smoking patients, which included a team approach, notification of the provider, unit manager, Coordinator in Patient Placement Center, and security when patients smoke in the hospital, the ordering of nicotine replacement therapy, security department are providing education and confiscating smoking materials, visitation restrictions can be imposed and patient searches as needed. If the patient can be safely discharged, this may be the plan but if the patient requires inpatient treatment an individualized care plan will be implemented.

In addition, during the tour of the neuro-physiology lab on 12 South and review of the Emergency Equipment logs, it was determined that the following dates December 3-4 and December 6-16, 2013, the neur-physiology lab staff assigned to check the emergency equipment (code carts) failed to sign and validate the emergency equipment checklist to authenticate that the equipment was ready for patient use in an emergent situation. In addition, on the day of the survey December 17, 2013 when staff was informed that equipment checks are necessary and per policy required, the surveyor found that the equipment had not been checked prior to providing services to patients entering the lab for test prior to the time the surveyor came on-site.

Review of the hospital's policy/procedure EQU 001Emergency Equipment the policy and procedure applies to all inpatient and ambulatory patient care settings and requires the charge nurse or designee to ensure completion of the checklist and replacement of any missing or malfunctioning items as early as possible during their shift. The policy further indicates that completion of the emergency equipment checklist will occur once per shift and after each use; however, there is no indication that staff in the Neuro-Physiology Lab had followed the policy/procedure or minimal standards for ensuring the equipment was checked at least daily. In the dental clinic in North Building, it was determined upon review of the Emergency Equipment checklist the staff had documented their initial for December 12-13, 2013 but did not check or validate that the equipment had been checked nor the crash cart lock number. On December 16-17, 2013 the checklist was blank. Again it is imperative that the staff check the Emergency Equipment in these outpatient areas to ensure the equipment is available and in working order when an emergency arises and the equipment should be checked before patients enter the area for treatment.

Based on a review of staff restraint education and the hospital " Use of seclusion and/or Restraints for Uncontrolled, Violent and/or Aggressive Behavior " (revised 10/13), it is revealed that the hospital uses a "Fall Management Enclosure System" or "Posey bed" which the hospital does not consider to be a restraint, yet trains staff that the enclosed bed is a restraint.

The hospital "Use of seclusion and/or Restraints for Uncontrolled, Violent and/or Aggressive Behavior" (revised 10/13), states in part, "B (e) Enclosure beds used for fall presentation are not considered behavioral restraints." Staff education on "Restraint Devices" (annual training) reveals "Enclosed Bed, Canopy comes attached to a hospital bed - it is considered a restraint and requires an order. Patient can move freely inside canopied bed. "

Whether used as a behavioral restraint or for fall prevention, the enclosed bed is a restraint, and would always require an order for use. While no enclosed bed restraint was in process at the time of survey, based on policy and training, the hospital fails to meet requirements for the use of enclosed beds.