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Based on medical record review, review of hospital policies, review of hospital documentation, observations, and interviews, the hospital failed to ensure a safe environment when subsequent to an electrical event in the operating room involving an occupied patient bed (Patient #200), five of fourteen patients reviewed for use of electrical equipment were found to be occupying beds that lacked yearly preventive maintenance (Patients #201, 211, 212, 213 and 214), failed to ensure that all staff were trained in hospital fire safety, and failed to ensure all staff were able to identify the PM status of electrical equipment. The findings include:


a. P #200 was admitted to the burn unit on 10/8/21 with 88 % total body surface area (TBSA) mixed full and partial thickness burns. P #200 was transported in the bed to the Operating Room (OR) on 10/18/21 for removal of eschar with skin grafting. Following the procedure, P #200's hospital bed (Total Care- from Vendor #1) was brought into the OR, plugged into the outlet, the patient was transferred back to the bed, and smoke was observed from the bed plug/outlet. P #200 was evacuated from the operating room and brought back to the burn unit in stable condition and without injury. Prior to plugging the bed into the wall on the burn unit, the cord to the bed was noted to be missing the ground prong of the plug and the end of the cord was charred. P #200 was transferred to another bed without incident. The hospital determined the fire started at the end of the bed plug as the wall socket had not been tripped. The ground prong was later retrieved from the OR wall socket and the wall socket was changed.

The immediate operative report dated 10/18/21 identified MD #200 (Surgeon), PA #200, MDs #201, #202 and #203 (Resident MDs), and RNs #202 and #203 were in the OR at the time the smoke was observed from the wall outlet area.

Interview with CRNA #200 on 10/19/21 at 10:34 AM and review of the Hospital policy entitled Fire Safety in the Operating Room identified that the OR staff followed the fire policy when the event occurred.

Interview with MD #201 on 10/19/21 at 11:49 PM noted that she pulled the bed's electrical cord and plug out of the socket when smoke was observed.

Review of the hospital's fire safety education and interview with the Manager of Regulatory Affairs on 10/20/21 at 11:21 AM identified that fire education was current for MDs #s 200, 202 and 203, PA #200, and RNs #s 202 and 203. The review and interview further identified that the hospital was unable to provide documentation for MD #201's education for fire safety and did not know if training had been provided.

An observation was made on 10/19/21 at 10:15 AM of P #200's bed that was used in the OR on 10/18/21 (and on the burn unit prior to 10/18/21). The bed plug was noted to be charred and the ground/neutral plug had broken off. The neutral plug was later retrieved from inside the red outlet in OR #4.

The investigation identified that there were no abnormalities identified with the bed or bed plug prior to the incident, and the bed had been PM'd in 8/2021.


b. Patient (P) #201 was admitted to the hospital burn unit on 10/7/21 with 5-6% total body surface area mixed full and partial thickness burns. Observation of P #201 on 10/19/21 at 9:47 AM noted P #201 in the bedside chair next to the bed and the patient's bed was plugged into the red wall socket. Further observation noted a bar code tag #1674001R009 attached to the bed's electrical cord, the cord had three prongs and was not damaged. The bed lacked a date for when Preventative Maintenance (PM) was due or when it was last performed.

The manufacturer's recommendations for the Progressa bed directed annual preventive maintenance be performed to include an examination of the plug for damage and a leakage current test using a testing device.

The service work order form by Vendor #1 identified that PM was performed for the hospital's Progressa beds on 9/27/18 and P #201's bed was included. Additional PM documentation for the Progressa beds could not be provided.

Interview with the VP of Support on 10/19/21 at 1:00 PM identified that the warranty for the nine Progressa beds that the hospital had in use expired on 9/27/19 and that PM was not performed in 2019, 2020 or 2021.

Interview with the VP of Support on 10/19/21 at 1:00 PM and on 10/20/21 at 1:28 PM identified when the warranty for the nine Progressa beds had expired on 9/27/19, the beds should have been added to the hospital's PM program, yearly PM had not been performed, and ultimately, he was responsible. Additionally, the VP on Support Operations indicated that Vendor #1 was the Vendor for all hospital beds. He further identified that Vendor #1 changed from a PM dated sticker to a bar coded system and staff would not know how to verify that PM was performed or due unless they called the vendor representative.

Interview with the Manager of Regulatory Affairs on 10/19/21 at 1:28 PM indicated that the hospital had a total of nine (9) Progressa beds in use and the hospital would begin to identify their location. She further noted that, beginning immediately, patients in those beds would be transferred to a bed that had updated PM.

A subsequent review of hospital documentation dated 10/19/21 identified that P #201, #211 and #212 occupied Progressa beds and were transferred to other beds on 10/19/21. P #213 and #214 occupied Progressa beds and were transferred to other beds on 10/20/21. PM for these five Progressa beds was performed by Vendor #1.

The hospital policy entitled Fire Safety in the Operating Room directed to ensure patient electrical equipment has current preventive maintenance prior to equipment use. Hospital required education entitled Electrical Safety directed recommendations for best practice for power cords and outlets. The hospital did not have a policy/education to direct staff to verify that patient equipment PM had been performed to include electrical beds.

The hospital policy entitled Patient Rights and Responsibility identified the patient has the right to care in a safe and secure environment.

Based on medical record review, review of hospital policies, review of hospital documentation, observations, and interviews, the hospital failed to maintain equipment to ensure an acceptable level of safety and quality. The findings include:


a. P #200 was admitted to the burn unit on 10/8/21 with 88 % total body surface area (TBSA) mixed full and partial thickness burns. P #200 was transported in the bed to the Operating Room (OR) on 10/18/21 for removal of eschar with skin grafting. Following the procedure, P #200's hospital bed (Total Care- from Vendor #1) was brought into the OR, plugged into the outlet, the patient was transferred back to the bed, and smoke was observed from the bed plug/outlet. P #200 was evacuated from the operating room and brought back to the burn unit in stable condition and without injury. Prior to plugging the bed into the wall on the burn unit, the cord to the bed was noted to be missing the ground prong of the plug and the end of the cord was charred. P #200 was transferred to another bed without incident. The hospital determined the fire started at the end of the bed plug as the wall socket had not been tripped. The ground prong was later retrieved from the OR wall socket and the wall socket was changed.

The immediate operative report dated 10/18/21 identified MD #200 (Surgeon), PA #200, MDs #201, #202 and #203 (Resident MDs), and RNs #202 and #203 were in the OR at the time the smoke was observed from the wall outlet area.

Interview with MD #201 on 10/19/21 at 11:49 PM noted that she pulled the bed's electrical cord and plug out of the socket when smoke was observed.

An observation was made on 10/19/21 at 10:15 AM of P #200's bed that was used in the OR on 10/18/21 (and on the burn unit prior to 10/18/21). The bed plug was noted to be charred and the ground/neutral plug had broken off. The neutral plug was later retrieved from inside the red outlet in OR #4.

The investigation identified that there were no abnormalities identified with the bed or bed plug prior to the incident, and the bed had been PM'd in 8/2021.

b. Patient (P) #201 was admitted to the hospital burn unit on 10/7/21 with 5-6% total body surface area mixed full and partial thickness burns. Observation of P #201 on 10/19/21 at 9:47 AM noted P #201 in the bedside chair next to the bed and the patient's bed was plugged into the red wall socket. Further observation noted a bar code tag #1674001R009 attached to the bed's electrical cord, the cord had three prongs and was not damaged. The bed lacked a date for when Preventative Maintenance (PM) was due or when it was last performed.

The manufacturer's recommendations for the Progressa bed directed annual preventive maintenance be performed to include an examination of the plug for damage and a leakage current test using a testing device.

The service work order form by Vendor #1 identified that PM was performed for the hospital's Progressa beds on 9/27/18 and P #201's bed was included. Additional PM documentation for the Progressa beds could not be provided.

Interview with the VP of Support on 10/19/21 at 1:00 PM identified that the warranty for the nine (9) Progessa beds that the hospital had in use expired on 9/27/19 and that PM was not performed in 2019, 2020 or 2021.

Interview with the VP of Support on 10/19/21 at 1:00 PM and on 10/20/21 at 1:28 PM identified when the warranty for the nine Progressa beds had expired on 9/27/19, the beds should have been added to the hospital's PM program, yearly PM had not been performed, and ultimately, he was responsible. Additionally, the VP on Support Operations indicated that Vendor #1 was the Vendor for all hospital beds. He further identified that Vendor #1 changed from a PM dated sticker to a bar coded system and staff would not know how to verify that PM was performed or due unless they called the vendor representative.

Interview with the Manager of Regulatory Affairs on 10/19/21 at 1:28 PM indicated that the hospital had a total of nine Progressa beds in use and the hospital and would begin to identify their location. She further noted that, beginning immediately, patients in those beds would be transferred to a bed that had updated PM.

A subsequent review of hospital documentation dated 10/19/21 identified that P #201, #211 and #212 occupied Progressa beds and were transferred to other beds on 10/19/21. P #213 and #214 occupied Progressa beds and were transferred to other beds on 10/20/21. PM for these five Progressa beds was performed by Vendor #1.

The hospital policy entitled Fire Safety in the Operating Room directed to ensure patient electrical equipment has current preventive maintenance prior to equipment use. Hospital required education entitled Electrical Safety directed recommendations for best practice for power cords and outlets. The hospital did not have a policy/education to direct staff to verify that patient equipment PM had been performed to include electrical beds.

The hospital policy entitled Patient Rights and Responsibility identified the patient has the right to care in a safe and secure environment.