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Based on documentation and interviews the hospital failed to protect the rights of patient #1 and other patients on the unit when patient #1 and patient #1's visitor used a cigarette lighter to ignite some papers in the patient's room and then stood on a chair and held the lighter (with flame) by the sprinkler head on the ceiling. The fire alarm and sprinkler system were activated, the locked doors opened, and patient #1 eloped from the locked unit with the visitor.

Findings include: The hospital failed to develop an effective system for protecting the rights of all patients (refer to A144) by closely monitoring contraband (lighter) that visitors attempt to bring into the hospital's locked unit. This failure places the Condition of Participation of Patient Rights out of compliance.

Based on documentation and interviews, the hospital failed to protect patients by having an effective system of monitoring and preventing contraband from being brought into the locked unit by visitors. As a result, patient #1 used a lighter to ignite some papers in her room and held the lighter by the ceiling sprinkler head causing the fusible link to fail, the water to flow and the alarm to be activated, and patient #1 eloped from the locked unit in one of eleven patients reviewed. Findings include:

Documentation in patient #1's medical record revealed that patient #1 was admitted to the hospital's Emergency Department (ED) on 6/13/15 related to a suicide attempt/Tylenol overdose. The patient had also broken a window on her car and used the glass to do cutting on both of her arms. Patient #1 was placed on a 72-hour hold and was transferred to the hospital's locked mental health unit for further evaluation, care and treatment. The patient was on every fifteen minute checks while she was on the unit.

A 6/15/15 discharge summary indicated patient #1's family member and significant other visited the patient during the early evening on 6/15/15. The two visitors became verbally aggressive with staff and demanded that the patient be released. The patient denied having ongoing suicidal thoughts and stated she wanted to go home. Staff informed the visitors and the patient that the patient could not leave due to the 72-hour hold. At approximately 7:00 p.m. on 6/15/15, the fire alarm sounded, and water was flowing from the sprinkler in the patient's room and down the hall. It was determined that there was a fire in the patient's room, and the police and fire department were notified. The locked doors on the unit automatically unlocked in response to the activation of the fire alarm system. Staff observed that the patient eloped from the unit with the visitor when the doors unlocked, and they were observed getting into a waiting vehicle.

Documentation and interviews revealed that one of the remaining twelve patients on the unit was discharged according to prior arrangements following the fire. The remaining eleven patients were transferred to other units in the hospital and closely supervised until they were promptly transferred to mental health units at other hospitals. The hospital's mental health unit was closed due to massive flooding, extensive water damage and the need for repairs.

The State Fire Marshal Division's 6/24/15 Investigation Report related to the 6/15/15 fire, was reviewed. The fire department responded to the activated fire alarm and noted a small fire that was extinguished by a single sprinkler in patient #1's room.The report stated the fire was caused by a person intentionally igniting combustibles (papers on the over-bed table) with an open flame. The heat generated by the small fire on the over-bed table was not sufficient to activate the sprinkler head so an open flame was held directly by the sprinkler head causing the fusible link to fail, the water to flow and the alarm to be activated. Video surveillance footage of the the mental health unit (prior to and after the alarm was activated) and digital photographs of patient #1's room taken prior to the fire scene being altered provided details related to the fire. The fire originated on patient #1's over-bed table and charred remains of paper napkins that had been burned were found in the patient's room. A wooden chair was positioned directly under the sprinkler head on the ceiling. A butane cigarette lighter was observed on the floor between the chair and the over-bed table.

The hospital's Contraband Policy, dated 7/9/14 and Visitation Policy, dated April 2011
were reviewed as they pertain to the mental health unit. The purpose of the Contraband policy is to provide guidelines for employees regarding the handling of contraband brought in by patients. Review of the two policies did not reveal that the mental health unit has a system and specific protocol in place that ensures that the visitors and their belongings are routinely checked for contraband. A lighter and matches are both identified as contraband in the Contraband Policy.

Administrative RN-(D) was interviewed in person on 6/22/15, and she stated that when the fire alarm sounded, the locked doors on the unit automatically unlocked, and patient #1 eloped from the unit with the visitor. The remaining twelve patients on the unit were immediately accounted for and closely monitored by staff. One of the twelve patients was discharged according to prior arrangements following the fire. The remaining eleven patients were temporarily transferred to other units in the hospital, including the Telemetry Unit and the Emergency Department. The eleven patients were monitored closely by direct care staff and security staff while they were on the other units. Additional staff were contacted by phone and asked to report to the hospital and provide assistance with monitoring the eleven patients. The eleven patients were transferred to mental health units at other hospitals by approximately 11:00 p.m. on 6/15/15.

Behavioral Health Technician-G was interviewed in person on 6/22/15, and she stated visitors are not checked for contraband prior to entering the mental health unit. There is a sign outside the main door that asks visitors to leave their belongings in a cupboard outside of the main door before entering the unit. A staff person does not monitor if that is being done, and it is more or less on an honor basis.

RN-H was interviewed in person on 6/22/15, and she stated visitors are not monitored for contraband prior to entering the unit.

Administrative RN-J was interviewed in person on 6/22/15, and she stated the hospital does not want this type of incident to occur again and has been discussing ways of preventing visitors from bringing contraband into the mental health unit. A definite plan has not been put in place. A possible intervention related to the issue would be to use a metal detector wand with visitors and visitors' belongings prior to visitors entering the unit. The wand could also be used when staff are searching patients for contraband. In addition, the possibility of decreasing visiting hours on the mental health unit, decreasing the number of visitors and requiring all visits to occur in the dining room have been discussed.