HospitalInspections.org

I. Based on review of policies, documents, and staff interview, the CAH (Critical Access Hospital) administrative staff failed to ensure the fire plan policy provided specific instructions for staff to follow that included staff contact of the local fire department when a fire occurs at the CAH.

Failure to develop and implement a fire plan policy with specific instructions for staff to follow if a fire occurred at the CAH resulted in staff failure to contact the local fire department when a fire occurred. This failure placed patients and staff at risk of injury, harm, and/or death.

The CAH reported a census of 9 patients at the time of the fire. Findings include:

1. Review of hospital policy titled, "Fire Plan" Revision date 10/15 included in part, "...Pull boxes are to be used in case the automatic alarm system does not work, or if the fire is seen premature to the alarm system detection..." The policy lacked specific instructions for staff to immediately contact the local fire department for any fire at the CAH.

2. During an interview on 10/22/15 at 11:45 AM, when asked if the Medical Surgical Manager worked on 10/19/15 when Patient #1 sustained injuries from a fire in the patient's room, the Medical Surgical Manager stated, "At approximately 6:45 PM I was walking down the hall and I could see the activity. When asked if staff contacted the local fire department, the Medical Surgical Manager stated, "They did not pull the fire alarm and did not contact the local fire department but we should have."

During a follow up interview on 10/26/15 at 11:47 AM, the Medical Surgical Manager stated, "A fire is an active fire versus a very quick flash of fire that was in the air."

During an interview on 10/26/15 at 11:05 AM, Registered Nurse (RN) F reported on 10/19/15 at approximately 6:40 PM she saw a flash in the window of Patient #1's room, heard a crackle, and then saw a white flash. When asked if she pulled the alarm box and/or contacted the local fire department, RN F stated, "I did not call the fire department because there was no fire. There was a flash of fire that I saw and by the time I got in there and got the gown off there was no fire. There's nothing I can do about that now."

During an interview on 10/26/15 at 10:30 AM when asked if RN D was present when the fire occurred in Patient #1's hospital room on 10/26/15, RN D stated, "I was the charge nurse. I was called to the room by [RN C]. When I entered the room there was no flash and no fire. I left the room and got [Emergency Department Physician] to come to the patient's room. We did not call the fire department because there was no fire." When asked if the CAH fire plan policy instructed staff to contact the fire department for fires, RN D stated, "I don't know what our policy says. I know if there is a fire, an automatic trip rings to the fire department."

During an interview on 10/27/15 at 8:00 AM, the Plant Manager reported the local fire department would not be notified for this type of fire. The Plant Manger stated, "If they observe a sustainable fire they are trained to pull the fire alarm. As soon as the fire alarm is pulled the system is activated to contact the fire department." The Plant Manager stated, "I should of been contacted at the time of the event."

During an interview on 10/27/15 at 1:30 PM, the Chief Nursing Officer reported the fire plan policy lacked information for staff to understand the definition of a fire.


II. Based on review of Critical Access Hospital (CAH) policies, procedures and staff interview the CAH administrative staff failed to develop and implement a patient safety plan for staff to be aware of all potential environmental safety risks such as observation or suspicion of patients or staff smoking in an area where oxygen is in use.

Failure to ensure administrative staff developed and implemented a patient safety plan for staff to be aware of all potential environmental safety risks including smells and/or visualizations of any indication of smoke, hazardous materials, cigarette lighters, etc. in patient treatment areas and/or suspicion of anyone smoking with oxygen is in use resulted in 1 of 1 patient that used a opened flame lighter (left in the patient's room) to light a cigarette that resulted in patient injury and harm. (Patient #1)


The CAH reported a census of 9 patients at the time of the fire. Findings include:

1. The CAH policy titled, "Patient Safety Plan" with a revision date of 1/15 lacked evidence of a specific plan for staff awareness of potential environmental safety risks including smells, observations, any indication of smoke, hazardous materials, cigarette lighters, etc. in patient treatment areas and/or suspicions of anyone smoking with oxygen is in use.

2. During an interview on 10/27/15 from 1:30 PM to 3:00 PM, the Chief Nursing Officer acknowledged the Patient Safety Plan lacked information for potential environmental safety risks and what actions are required.

I. Based on review of policies, procedures, medical records, documents, and staff interview, the Critical Access Hospital (CAH) failed to ensure:


1. Administrative staff developed and implemented a system that provided education for patients on oxygen safety to include the risks of smoking with the use of oxygen. (Refer to C 274)

2. Administrative staff developed and implemented an oxygen safety policy to include the risk of smoking when oxygen is in use and posted no smoking when oxygen is in use. (Refer to C 275)

3. Administrative staff assigned nursing staff to perform ongoing assessments and evaluations for a patient's nicotine withdrawal symptoms and performed an assessment to remove environmental risks from the patient's room as indicated. (Refer to C 296)

4. Staff developed and implemented a patient care plan to meet the needs for a patient with a history of tobacco dependency. (Refer to C 298)

5. Staff developed a patient care plan to meet the needs for patient with a history of tobacco dependency to assist the patient with nicotine withdrawal. (Refer to C 298)

The CAH reported a census of 9 patients at the time of the fire. The cumulative effect of these systemic failures and deficient practices resulted in the hospital's inability to ensure the safe care and provision of services for a medical surgical patient who received oxygen.

II. During the self-reported incident investigation, the surveyor identified an Immediate Jeopardy (IJ) situation, A situation that placed the patients at risk for harm, related to the Condition Provision of Services 42 CFR 485.635.

1. The Administrative staff failed to develop and implement a corrective action plan to ensure all patients would receive care in a safe setting and free from potential environmental safety risks following a fire on 10/19/15 in a patient's hospital room. (Patient #1)

2. The administrative staff took action and put a corrective action in place and removed the Immediate Jeopardy prior to the exit date of the self-reported investigation. A condition level deficiency remained for the Condition: Provision of Services.

The corrective action plan included in summary:

The Fire Plan Policy was revised with the definition of a fire. The Registered Nurses (RNs) and Certified Nursing Assistants (CNAs) received education on the Fire Plan policy on 10/27/15 and all CAH staff received education beginning on 10/29/15.

The Chief Nursing Officer reported on 10/27/17, the RNs and CNAs received education on the importance of potential environmental safety concerns. The Patient Safety Plan policy was revised to include investigation and notification of environmental safety events. Following a fire or potential fire, all equipment involved will be immediately removed from service and no equipment, supplies, or material involved in a fire or any event investigation will be discarded.

The Chief Nursing Officer reported the nursing staff were educated to perform surveillance and environmental search of the patients' hospital rooms, to be aware of potential environmental safety concerns, and to remove all potential safety risks from patients' rooms.

Based on review of policies, medical records, and staff interview, the Critical Assess Hospital (CAH) failed to ensure administrative staff developed and implemented a policy to provide education for patients regarding oxygen safety that included the risks of smoking with the use of oxygen.

Failure to develop and implement a policy that provided education on oxygen safety for patients to include the risks of smoking with the use of oxygen, resulted in staff failure to educate 1 of 1 patient on the risk of smoking with the use of oxygen, which resulted in a fire, patient injury, and patient harm. (Patient #1)

The CAH reported a census of 9 patients at the time of the fire. Findings include:

1. Review of a policy titled, "Safety Around Oxygen" Revision Date 1/04, failed to include the risks of smoking with the use of oxygen.

Review of hospital policy titled, "Multidisciplinary Patient Teaching" reviewed 4/15, revealed the following in part, "...Patient teaching...is most effective when initiated as soon after admission as possible...assess patient learning needs...daily or as condition changes...presentation...smoking policy."

Review of hospital policies and procedures failed to include a policy or procedure to provide education for staff and patients on oxygen safety and the risks of smoking with the use of oxygen.

2. During an interview on 10/26/15 at 1:30 PM, Registered Nurse (RN) G reported on 10/17/15 she admitted Patient #1 from the emergency department. When asked if RN G educated the patient on oxygen safety and the risks of smoking, RN G stated, "I did not begin teaching the patient regarding smoking cessation because I was focused on the patient's respiratory distress and rapid respirations."

During an interview on 10/26/15 at 10:35 AM, the Respiratory Therapist (RT) E stated, "I didn't teach [Patient #1] no smoking with oxygen precautions because there is no smoking precautions in the hospital." RT E stated "I asked [Patient #1] how many packs of cigarettes he smoked and the patient admitted it was 2-3 packs a day." RT E stated, "I offered the patient non-smoking literature but it was declined." RT E reported he did not review oxygen precautions, the tobacco free campus literature packet, or verbally tell the patient not to smoke when oxygen is being used.

During an interview on 10/27/15, when asked if Physician A expected staff to educate patients on the risks of smoking when on oxygen, Physician A stated, "I would expect the nursing staff to educate patient's about oxygen safety, and immediately intervene if they suspected a patient was smoking when oxygen was being administered."

Based on review of policies and staff interview the Critical Access Hospital (CAH) administrative staff failed to develop and implement an oxygen safety policy to include the risk of smoking while using oxygen and posted no smoking signage when oxygen was in use.

Failure to ensure administrative staff developed and implemented an oxygen safety policy to include the risk of smoking and posted no smoking signage when oxygen is in use resulted in 1 of 9 patients on oxygen using an open flamed lighter in an attempt to light a cigarette resulting in a fire, patient injury, and patient harm. (Patient #1)

The CAH reported a census of 9 patients at the time of the fire. Findings include:

1. Review of a policy titled, "Safety Around Oxygen" with a review date of 7/14 revealed the policy lacked information to include patient education of no smoking and posting of no smoking signage in the patient room when on oxygen.

2. During an interview on 10/22/15 at 11:45 AM, the Medical Surgical Manager acknowledged the "Safety Around Oxygen" policy did not include the risks of smoking with oxygen use.

3. During an interview on 10/27/15 At 8:00 AM, when asked if the staff posted no smoking oxygen in use signs in the patient's rooms, the Plant Manager reported the staff do not post no smoking oxygen in use signs in the patient rooms. The Plant Manager stated, "There should have been signs in rooms where oxygen is being used."

4. During an interview on 10/27/15 at 1:30 PM, the Chief Nursing Officer (CNO) acknowledged the "Safety Around Oxygen" policy lacked oxygen safety guidelines that included the risks of smoking while oxygen was in use.

Based on review of hospital policies, procedures, medical records, documents, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure nursing staff assigned to nicotine dependent patients on oxygen therapy assessed patients needs, evaluated patient's response to interventions, and performed an assessment of the patient when there was a suspicion of hazardous material in the patient's hospital room.

Failure to ensure staff performed ongoing assessments and evaluations for 1 of 1 patient's nicotine withdrawal symptoms, evaluated the patient's response to the use of a nicotine patch, and performed an assessment and evaluation of the patient when staff smelled smoke, saw a cigarette lighter, and cigarette butts in the patient's room resulted in a fire, patient injury, and patient harm. (Patient #1)

The CAH reported a census of 9 patients at the time of the fire. Findings include:

1. Review of a policy titled, "Nurse-Practitioner Communication Regarding Patient Care Issues in the Chain of Command" Revision Date 4/14 included in part, "...Every Registered Nurse...is responsible for his/her actions in administering patient care and securing medical attention for the patient when necessary..."

Review of a policy titled, "Nursing Care Responsibilities" Revision Date 4/15 included in part, "...The determination of nursing staff member's current clinical competence and the assignment of nursing care responsibilities are the responsibility of the Clinical Nursing Directors and Supervisors...Considerations will be made when nursing care responsibilities are assigned to a nursing staff member...The complexity of the assessment required by the patient..."

Review of hospital policy, procedure, "General Rules of Hospital Safety" reviewed 10/14 revealed the following in part, "...Safety is the responsibility of each employee...observe smoking regulations...apply a healthy dose of common sense to everything you do on the job."

2. Review of Patient #1's medical record revealed:

a. On 10/19/15 at 4:30 PM, Staff M, Certified Nursing Assistant's (CNA's) documentation included in part, "...Reported to patient's nurse and charge nurse along with other nursing assistant that patient's room smelled like smoke. Suspicions of patient smoking in room..."

b. On 10/19/15 at 4:32 PM, Staff H, CNA's documentation included in part, "...reported to nurse that patient might be smoking in room...smelled smoke and spotted butts in the trash can...unsmoked tobacco on floor by patient..."

c. On 10/19/15 at 4:33 PM, Staff H, CNA's documentation included in part, "...saw a lighter in patient's room...reported to nurse..."

d. Patient #1's medical record lacked evidence that showed Registered Nurse (RN) F performed an assessment and/or intervened after CNA M and CNA H reported they smelled smoke, found cigarette butts, a lighter, and tobacco in Patient #1's room.

3. During an interview on 10/26/15 at 11:05 AM when asked if RN F performed a patient assessment and intervened when [CNA M and CNA A] told her they smelled smoke, found a lighter, saw cigarette butts in the trash can, and saw tobacco on the floor, RN F stated, "[CNA H] told me she thought she smelled smoke in [Patient #1's] room. I went in the room about five minutes later. When asked if RN F searched the room, and questioned the patient in regards to smoking in the room, RN F stated, "I didn't document anything. I went in there and asked what [Patient #1] was doing. I didn't ask if [Patient #1] was smoking. I didn't smell fresh cigarette smoke. I had no reason to believe [Patient #1] was smoking." When asked if RN F found a lighter, cigarette butts in the trash can, and tobacco on the floor, RN F stated, "I don't remember [CNA H] telling me she saw cigarette butts. I didn't search the room. After the fact, we found three cigarette butts and tobacco on the floor. I saw a lighter later, one of the nurses had it." RN F stated "In hindsight (Understanding of a situation or event after it happened.) yes, of course I should have searched the room and asked the patient questions."


During an interview on 10/26/15 at 10:20 AM, Nursing Supervisor, RN D reported she was the shift coordinator on 10/19/15. RN D stated, "I was present when CNA H and CNA M told RN F that they smelled smoke, saw a cigarette lighter and cigarette butts in the trash can in the patient's room." When asked if RN D searched [Patient #1's] room, RN D stated, "[RN F] was the patient's primary nurse, I assumed she would follow through with an assessment of the patient after the CNA's told her what they observed." Staff D stated, "At approximately 6:40 PM I was called to [Patient #1's] room and when I entered the room the patient's face was black, the nasal cannula (oxygen tubing) was burnt and the prongs were burnt off. The patient's gown was off and there was a burned area on the top of the patient's right hand, forehead, and left check area of the patient's face."

4. During an interview on 10/26/15 at 11:47 AM, the Medical Surgical Manager reported she was present on 10/19/15 when the fire occurred in Patient #1's room. When asked if the Medical Surgical Manager found a lighter, cigarette butts, or tobacco in the patient's room, the Medical Surgical Manager stated, "The staff showed me 2 smashed, burned colored cigarette butts from the patient's garbage can." The Medical Surgical Manager acknowledged the CNAs and nursing staff failed to search the patient's room and belongings for evidence of smoking with oxygen use and nursing staff failed to perform an assessment of the patient when the CNAs reported they smelled smoke, found a lighter, and cigarette butts in the garbage can.

5. During an interview on 10/26/15 at 3:00 PM, CNA H reported on 10/19/15 at approximately 4:30 PM, she smelled fresh smoke when she entered Patient #1's room. CNA H stated, "I saw [Patient #1] bend down to pick up a green BIC (brand) lighter off the floor. I nonchalantly looked in the garbage can next to the patient and saw three to five cigarette butts and the filters were brownish colored." When asked if CNA H removed the lighter and reported the incident, CNA H stated, "I told both [RN F and RN D] that I smelled smoke and what I saw." When asked why CNA H didn't remove the lighter, CNA H stated, "I wasn't sure about where my scope of practice ends and where the nurses scope of practice begins. I documented what I saw in the patient's record. I thought that's what I needed to do."

6. During an interview on 10/27/15, Physician A stated, "When I saw [Patient #1] the morning of 10/19/15, the patient was "itching" (To have a restless desire to do something.) to smoke and asked to go outside." Physician A reported he told the patient no and the nicotine patch along with the PRN (as needed) medications would help with the anxiousness from not being able to smoke and the nicotine withdrawal symptoms. Physician A stated, "I would expect the nursing staff to assess the patient for nicotine withdrawal symptoms and administer medications as needed." Physician A stated, "When [RN D] contacted me that night I thought it was a joke but when I arrived to the hospital and saw the patient's face covered with black soot I knew it wasn't." Physician A reported he transferred Patient #1 to the [Hospital B] burn center.

7. Review of Patient #1's medical record from Hospital B (receiving hospital) showed a document titled, "History and Physical Burn Assessment Note" dated 10/19/15 at 11:53 PM included in part, "...On O2 (oxygen) sustained a flash face burn when someone in the room attempted to smoke a cigarette. Burns sustained to face and hands, approximately 1% TBSA (total body surface area)...endoscopy showed injuries to nares, mild vocal cord edemas..1% TBSA burn to face with blanching superficial burns...singed nares, mild edema of uvula...superficial burns to bilateral hands..."

Based on medical record review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure staff developed a patient care plan to include tobacco dependency goals, interventions, ongoing assessments, and reassessment for a patient with a history of nicotine dependency.

Failure to ensure staff developed a patient care plan to meet the needs for 1 of 1 patient with a history of tobacco dependency resulted in the lack of implementation of goals and interventions. Staff failed to evaluate and perform assessments to assist the patient with nicotine withdrawal.

Failure to ensure staff assessed the patient's tolerance of decreased nicotine absorption with use of the physician ordered nicotine patch resulted in patient harm when a patient on oxygen attempted to light a cigarette in the patient's hospital room. (Patient #1).

The CAH reported a census of 9 patients at the time of the fire. Findings include:

1. Review of Patient #1's medical record showed the following:

a. Review of a document titled, "History and Physical" dated 10/17/15 included in part, "Tobacco Use...Cigarettes 3 packs daily 50 years (150,000 Pack Years)..."

b. Review of a document titled, "Patient Care Plan Report" dated 10/17/15 included in part, "...Teach and Provide Written Smoking Cessation Teaching Material If Appropriate, On Admit..."

c. Review of a document titled "Daily Focus Assessment Report" dated 10/17/15 included in part, "...At 4:06 PM (approximately 42 minutes after the patient was admitted)...Patient refused the aids to assist in the cessation of nicotine use...Materials were not delivered to patient..." The Medical record failed to show staff offered Patient #1 the smoking cessation material on 10/18/15 or 10/19/15.

d. Review of Physician's orders dated 10/17/15 included in part, "...Ativan 1 milligrams (mg) (Used to treat short term anxiety.) intravenous every 6 hours as needed (PRN) agitation... Nicotine 21 mg/24 hours transdermally every 24 hours (equivalent to 1 pack of cigarettes per day)..." Review of the medication administration record showed staff did not administer the PRN Ativan on 10/19/15 after Patient #1 asked Physician A to go outside and smoke.

e. Review of a document titled, "Daily Focus Assessment Report" dated 10/18/15, Registered Nurse (RN) I documentation at 3:15 PM included in part, "...Now reports hip pain. During assessment denied pain...See MAR (Medication Administration Record) for RX (Medication). Also requesting "Nicotine patch" for "50 year history of three packs per day" smoking habit. See MAR...Continue plan of care..." The plan of care lacked evidence to show staff established patient goals, developed interventions, performed assessments to evaluate patient's tolerance to no smoking during the hospitalization and the risks of smoking during the use of oxygen.

2. During an interview on 10/22/15 at 2:50 PM, Staff A, Medical Surgical Manager acknowledged nursing staff failed to establish a patient care plan for Patient #1 to include tobacco dependency and withdrawal symptoms.

During a follow up interview on 10/26/15 at 11:47 AM, the Medical Surgical Manager stated, "This event was avoidable if we would of done something from the beginning. If we would of intervened with not only the nicotine patch but provided support and reassurance about not smoking when the patient is on oxygen." The Medical Surgical Manager reported the staff should of offered the PRN medications, reassessed the patient for signs and symptoms of nicotine withdrawal, and intervened accordingly.

3. During an interview on 10/26/15 at 4:30 PM, the Chief Nursing Officer (CNO) acknowledged nursing staff failed on to prepare an appropriate patient care plan for Patient #1 to include tobacco dependency that ensured the staff were monitoring the patient for signs and symptoms of nicotine withdrawal. The CNO stated, "Whether or not that would have prevented what happened, we will never know." The CNO stated, "the nurses received education when they are hired on the development of care plans. The nurses know the care plans are individualized to all patients. The nurses are expected to make revisions as needed if they determine it is necessary."

Based on review of the Critical Access Hospital (CAH) policies, procedures, documents, Medical Staff By-laws, medical records, and staff interview, the CAH failed to ensure the Emergency Department (ED) physician documented an assessment of 1 of 1 patient condition, treatment, and physician orders following a fire which resulted in patient injury.

Failure to document an assessment, patient condition, and physician's orders following a fire that resulted in patient injury does not validate the history of events, condition of the patient, and any treatment orders carried out. (for Patient #1)


The CAH reported a census of 9 patients at the time of the fire. Findings include:

1. Review of CAH policy, procedure titled, "Medical Staff Rules for Medical Record Documentation, reviewed 4/15 included in part, "...to insure that the medical record contains sufficient information to support the diagnosis, justify the treatment, document the course and results accurately...the content of the health record shall include but not limited to...identification of the patient...treatments rendered...progress notes shall reflect information to supplement or support the diagnosis, justify the treatment...support the severity of illness...as well as to reflect specific disposition of the case."

2. Review of document titled, "Medical Staff Rules and Regs" reviewed and amended 12/14, included in part, "...the attending practitioner...involved in the care of a patient shall be responsible for the preparation of a complete...medical record...the medical record shall include...description and history of present complaint/illness...physical examination report...treatments provided...progress notes and other clinical observations...final diagnosis."

3. Review of Patient #1's medical record lacked evidence of an ED physician's documented assessment of the patient's condition, treatment, and physician orders following a fire which resulted in patient injury.

4. During an interview on 10/22/15 at 3:40 PM, the Chief Nursing Officer (CNO) acknowledged ED Physician B failed to document an assessment of the patient's condition, treatment, and the physician orders following the fire that caused Patient #1's injuries. The CNO acknowledged ED Physician B failed to follow the CAH policies, procedures, and Medical Staff Rules and Regulations. The CNO reported if a physician is unable to complete documentation at the time of the event, the physician is expected to complete all documentation by the end of the shift. The CNO reported she contacted [ED Physician B] to complete the documentation to support Patient #1's assessment, treatment, and physician's orders.

5. Review of a document titled "Regarding patient with in-hospital burn" Dated: 10/22/15 (Received from the CNO) included in part, "...date of injury 10/19/15...on 5 liters of oxygen by nasal cannula ...told the patient flicked a lighter and had caught fire to his face, mustache, and hands ...upon arriving to the room the patient was noted to be in moderate distress with soot to face and bilateral hands, with several small round burns to abdomen. I evaluated the burns and determined he needed to be transferred to [Hospital B] burn unit for more intensive burn care...had second and third degree burns to...face. Likely full thickness burns to..bilateral nares (bilateral nostrils) which were charred but patent...able to breathe...simple mask at 6 liters per minute...oxygen saturations increased...not in respiratory distress...evaluated... oropharynx (back of throat) and noted no soot, only mild erythema to the uvula and no swelling...instructed paramedics to evaluate his airway to prepare for transfer should they need to intubate him along the way as I felt...didn't need intubation yet. By this point ...[Physician A] was able to respond ...I advised him of my recommendations ...Mercy 1 helicopter was contacted for transport at this point I was no longer involved....ED Physician B..."