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Based on review of the facility's fire drill reports, staff interview, observation of the psychiatric unit, review of staff meeting minutes for the months of April, May, and June, 2012, review of the hospital's quality safety committee reports, and staff interview, the facility failed to ensure one (Patient #3) of five patients reviewed received care in a safe setting; to ensure staff were adequately trained to respond appropriately and effectively during a fire emergency. This placed all patients at risk.
The total patient census was 72.
The cumulative effect of this systemic deficient practice resulted in the hospital's inability to ensure patient safety.

Findings include:

Review of the hospital's fire drill reports revealed, prior to the 06/04/12 fire, a fire drill had been conducted on 05/25/12, on the psychiatric unit. In the comment section of the fire drill report the following comment evaluating the drill stated "need keys made up for fire extinguisher cabinets." There was no documentation of the facility's follow up of this recommendation.

The quality safety committee report, dated 06/04/12, stated a sign would be placed at the entrance to the unit making visitors aware not to give patients lighters or matches, tobacco products, weapons, contraband, glass or aluminum cans. However, during the direct observations on the unit on 7/11/12 and 7/12/12, there were no signs posted to make visitors aware of these precautions.

Review of the staff meeting minutes from the month of June, 2012, revealed the fire drill incident had been acknowledged but no recommendation was offered to address the incident.

The documentation of staff orientation to the psychiatric unit was reviewed and revealed a lack of documentation of fire safety instructions to employees specifically, the location and use of the fire extinguishers, the responsibilities of the individual staff members, where to take patients, who is to call 911, the security of patient medical records, and who assists with these psychiatric patients.

The above findings were confirmed with Staff A, B, C, and D on 7/13/12 at 3:30 PM.

Refer to A144 for specific findings.

Based on medical record review, staff interview, observation of the psychiatric unit, review of staff meeting minutes for the months of April, May, and June, 2012, and review of the hospital's documentation of the fire drills, the facility failed to ensure one (Patient #3) of five patients reviewed received care in a safe setting. The total patient census was 72.

Findings include:

The medical record review for Patient #3, completed on 07/11/12, revealed the patient was admitted on 06/02/12 with a history of psychosis as a diagnosis. The patient was brought to the hospital by his mother. This was the patient's second psychiatric emergency service (PES) visit in a week. The psychiatric emergency admission note stated," The patient is a 20 year old African-American male with a past history per the patient's mother of schizophrenic and bipolar disorder. The patient was evaluated and admitted to the psychiatric unit. The nursing progress notes dated 06/03/12 at 5:50 AM., stated "Patient in hall way after patient's room on fire. Patient denies knowing anything about how or why".

The patient was asked for permission to be searched by police, security and staff, but the patient refused and became verbally abusive, verbally threatening and was making hostile gestures. Patient was assisted to the seclusion room to be searched and began to fight staff. The on duty Resident physician was on the unit and evaluated/assessed the patient. The patient was given stat emergency medications (schizophrenic/bipolar use) 20 milligram intramuscular and Ativan (anti-psychotic) two milligram imtramuscular. The patient remained in the locked seclusion with 15 minute observation checks by staff. Nothing was found on the patient during the search related to fire starting materials.

The local fire authority that was on the unit stated the patient will be charged with arson and placed on police hold. The staff was to continue to monitor the patient for safety.

An interview conducted on 7/11/2012 at 10:00 AM., with administrative staff (Staff C), regarding the incident on 06/03/12 revealed the following; "Fire alarm went off around 5:00 AM. Front desk operator announced code red 3578. Staff confused about room number since number on door sign reads 578. Other staff in hospital reported they ran down to 3rd floor looking for room! A registered nurse (Staff O) opened (the) door and observed 2-3 feet of flames coming off (the) middle of (the) mattress and closed the door. Staff ran to get fire extinguisher but (the) keys would not work. Staff P's, another registered nurse on unit, key would not work. Finally, Staff O's key would only work partially and (Staff O) had to break (the) case to get (the) fire extinguisher. Staff P ran into the room with extinguisher (and) sprayed (the) fire/area and put (the) flames out but (the) room became filled with dark black smoke. Staff P came out and closed the door.

Then maintenance worker/boiler room lady (Staff Q) started taking buckets of water to room to put out fire. While other staff begin going to each room to wake patients to get out of rooms, moving them to hallway then to dining room. The fire department on unit, secured fire and area. All staff and patients were not injured."

Prior to the fire incident of 06/04/12, there was a 05/25/12, fire drill on the psychiatric unit. The comment section of the evaluation form stated "need keys made up for fire extinguisher cabinets." There was no documentation of follow up of this recommendation. There was no documentation available for review to support that each staff member was trained in what to do during a fire.

Staff C verified during an interview on 07/13/12 at 10:00 AM, staff had re-entered the room after trying to put out the fire with the extinguisher. The staff entered the room again with buckets of water. Interview with Staff C indicated that if a fire is not contained with the extinguisher and/or water, the door is to be closed and contained.

The safety committee report, dated 06/04/12, stated a sign would be placed at the entrance to the unit making visitors aware not to give patients lighters or matches, tobacco products, weapons, contraband, glass or aluminum cans. However, during the direct observations on the unit on 7/11/12 and 7/12/12, there were no signs posted to make visitors aware of these precautions.

Review of the staff meeting minutes from the month of June, 2012, revealed the fire drill incident was acknowledged but no recommendation was offered to address the incident.

The documentation of staff orientation to the psychiatric unit was reviewed and revealed a lack of documentation of fire safety instruction to employees, specifically, the location and use of the fire extinguishers, the responsibilities of the individual staff members, where to take patients, who is to call 911, security of patient medical records, and who assists with these psychiatric patients.

The above findings were confirmed with Staff A, B, C, and D on 7/13/12 at 3:30 PM.