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Based on document review and interview it was determined that the Hospital failed to provide care in a safe environment. As a result, the Condition of Participation 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure that contraband checks were completed in all behavioral health patient rooms, subsequently a patient used a lighter (contraband) to set a mattress on fire. (A-144)

The Immediate Jeopardy began on 10/10/2021 due to the Hospital's failure to conduct contraband checks in each behavioral health unit patient room, subsequently a behavioral health unit patient used a lighter to set her mattress on fire; and was identified on 1/25/2022, at 42 CFR 482.13, Patient Rights. The IJ was announced on 1/26/2022 at 3:20 PM, during a meeting with the President/Chief Executive Officer and the Vice President of Quality and Performance Improvement. The IJ was not removed by the survey exit date of 1/26/2022.

Based on document review and interview, and observation, it was determined that for 1 of 1 patient (Pt #1) reviewed for incidents related to contraband on a behavioral health unit, the Hospital failed to ensure Pt #1 received care in a safe setting by not conducting environmental rounds and contraband checks. This failure resulted in Pt #1 setting her mattress on fire with a lighter.

Findings include:

1. On 1/24/2022, the Hospital's policy titled, "Body Check and Personal Belonging Search" (dated 9/1/2021) was reviewed and required, "It is the policy of the Hospital, Department of Psychiatry that Body Checks and Personal Belongings searches are done to ensure optimal safety for the patient and others, including all team members ...Procedure for Body Check - if a patient is suspected of hiding any contraband on their person, the patient is asked to squat and cough while covered to dislodge any hidden contraband ..."

2. On 1/24/2022, the Hospital's policy titled, "Patient Safety Rounds" (dated 9/1/2021) was reviewed and required, "The beginning of each shift, an incoming and an outgoing Mental Health Specialist will conduct joint rounds identifying each patient and any other safety issues on the unit..."

3. On 1/24/2022, Pt #1's clinical record, dated 10/2/2021 to 10/28/2021, was reviewed and indicated:
-Crisis Intervention Assessment, dated 10/2/2021, noted, "Pt #1 escorted to ER on 10/2/2021 by police after being found nude in front of the residential facility that she used to live at ...Pt #1 has not been taking her medications and it appears that Pt #1 is homeless and as a result her psychotic symptoms have increased ...Pt #1 is in need of hospitalization at this time for stabilization ...schizophrenia ..."
-Pt. #1 was admitted to the 3 East Women's Behavioral Health Unit on 10/2/2021 and was discharged on 10/28/2021.
-Pt. #1 was on assault, seizure, and fall precautions throughout her admission.
- ED Technician (E #10)'s admission ED contraband search, dated 10/2/2021, noted "contraband search and body check completed - normal exam."
-Psychiatry daily progress note, dated 10/10/2021, indicated, "Staff reported Pt #1's bed was on fire ...continues to require further inpatient hospitalization ..."

4. On 1/24/2022, the Hospital's incident report, dated 10/10/2021 at 7:10 AM, indicated:
-"Pt #1 set fire to a mattress in her room. Pt #1 had the lighter concealed in her private areas...Public safety monitored the entry and exit points until the unit can be resecured. E #3 (Public Safety Officer) stated that when asked about what started the fire, Pt #1 [slid her diaper to the side, Pt #1 reached in her privates and removed a lighter from the area]. Pt #1 stated that she found the lighter in the hallway."

5. On 1/24/2022, the environmental rounds forms for 3 East/female Behavioral Health Unit (10/1/2021 - 1/25/2022), were reviewed. The environmental rounds forms included the following directions, " ...A visual check for contraband items must be completed and documented (checked off) for each room and common area each time environmental rounds are done." The environmental rounds required contraband checks. The environmental rounds lacked documentation that every patient room was checked. The environmental rounds form did not include room #363 (Pt #1's Room where she set her bed on fire) on the form. Therefore, no environmental rounds/contraband checks were documented as being completed for room #363 from 10/1/2021 -1/25/2021.

6. On 1/24/2022, the root cause analysis, completed by the Hospital on 10/10/2021 following the fire incident, was reviewed and did not identify any changes that were implemented regarding environmental rounds or the addition of Room 363 to the environmental rounds sheet.

7. On 1/24/20222 at 11:00 AM, an interview was conducted with the Director of Quality (E #2). E #2 stated that he did the root cause analysis regarding the fire incident. E #2 stated that contraband searches are conducted on admission. E #2 stated that Pt #1 was able to hide a lighter in her vagina on admission (8 days prior to the incident).

8. On 1/24/2022 at 12:45 PM, an interview was conducted with the Public Safety Officer (E#3). E #3 stated that he responded to the code red on the BHU on 10/2/2021. E #3 stated that after all the patients were safely moved and the fire was put out, he interviewed Pt #1 regarding the fire. E #3 stated that when he asked Pt #1 about what started the fire, Pt #1 slid her diaper to the side, put her fingers in her vagina and pulled out a lighter. E #3 stated that Pt #1 told him that she found the lighter in the hallway.

9. On 1/24/2022 at 1:45 PM, an interview was conducted with E #10. E #10 stated that Pt #1's admission (dated 10/2/2021) contraband search was normal. E #10 stated that Pt #1 coughed and squatted for the contraband search and nothing came out of Pt #1's vagina or rectum. E #10 stated that a contraband search is conducted on all psychiatric patients.

10. On 1/24/2022 at 10:43 AM, an interview was conducted with a Mental Health Specialist (E #4) was interviewed. E #4 stated that she was on duty on when Pt. #1 set her mattress was on fire. E #4 stated that she did not see the fire, but she saw a lot of smoke. E #4 stated that Pt. #1 stated that she (Pt. #1) found the lighter in the hallway and used it to set the fire.

11. On 1/25/2022 at 12:42 PM, an interview was conducted with a Mental Health Specialist (E #7). E #7 stated that room 363 is a patient room. E #7 stated that in the past, room 363 was not a patient room, and the environmental rounds form has not been updated to include room 363. E #7 stated that contraband checks are conducted with the environmental rounds on each shift (day, evening, and night). E #7 stated that the contraband search is conducted to find items that can harm patients such as weapons, lighters, and ligatures.

12. 14. On 1/24/2022 between 10:15 AM - 10:55 AM, an observational tour of 3 East (female Behavioral Health Unit). There were 2 Registered Nurses and 2 Mental Health Specialist providing care for 12 patients. There were two patients in room 363. The patient in 363 bed 1 had precautions for suicide, assault, and elopement. The patient in 363 bed 2 had precautions for assault and suicide. The environmental rounds form for 1/24/2022 did not include room 363 to indicate that environmental rounds or contraband checks had been completed for that occupied patient room.