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Based on document review and interview, it was determined for 1 of 2 (Pt. #2) patients involved in starting a fire, the Hospital failed to ensure patients did not have access to contraband (lighter, matches, weapons, etc.), thus putting all 16 patients on census, as well as staff, at a serious safety risk for harm. Refer to deficiency at A-144. As a result, it was determined that the Condition of Participation for Patient Rights 482.13 was not in compliance.

1. The Hospital failed to ensure patients did not have access to contraband (lighter, matches, weapons, etc.). See deficiency at A-144.


The immediate jeopardy (IJ) began on 5/17/17 when the staff smelled smoke and Pt. #2 was found to have a lighter in his possession, followed by no change in monitoring precautions for Pt. #2. Pt. #2 was able to access another lighter and start a fire to his mattress on 5/18/17. The fire required an evacuation of the 16 patients on the 4 East unit. In addition, the Hospital failed to implement effective corrective actions to ensure nonrecurrence.

An IJ was identified and announced on 5/23/17 at 1:42 PM, during a meeting, with the Senior Vice President of Patient Care and the Vice President of Quality and Compliance. The immediate jeopardy remains at the survey exit date of 5/24/17.

Based on document review and interview, it was determined for 1 of 2 (Pt. #2) patients involved in starting a fire, the Hospital failed to ensure patients did not have access to contraband (lighter, matches, etc.). This immediately affected the 16 patients on census and potentially the remainder of people in the hospital.

Findings include:

1. The Hospital policy titled, "Contraband Searches (revised September 2006)" was reviewed on 5/22/17. The policy included, "The patient will be asked if they have any contraband, smoking materials, or weapons. The patient will be asked to empty the contents of all pockets onto the bed for inventory. ... The patient will be asked to remove all of their clothes and to put on a hospital gown. ... All contraband items discovered during the search will be removed and handled appropriately. After completing the contraband search and inventory of the patient belongings and valuables Public Safety will sign the inventory sheet. Upon arrival to the unit a second contraband search and re-inventory of the patients belongings will be conducted by Public Safety and nurse from the receiving unit".

2. The Hospital policy titled, "Behavioral Medicine Visiting Rules (Revised August 2006)" was reviewed on 5/23/17. The policy included, "All packages will be inspected... All visitors will be documented - sign in on visitors log".

3. The clinical record of Pt. #2 was reviewed on 5/22/17. Pt. #2 was a 23 year old male admitted on 5/16/17 with the diagnosis of schizoaffective disorder. The psychiatric evaluation dated 5/16/17 included, " ...Angry and hostile ...Auditory hallucinations and paranoia ...Insight and judgment poor ... reality testing is poor. Diagnosis: ... cannabinoid (marijuana) use disorder. Treatment Plan: 1. Patient is admitted on locked adult inpatient psychiatric unit. 2. Close observation (every 15 minute safety checks) ..."

4. The Charge Nurse (E#2) on duty the evening of 5/18/17 was interviewed on 5/22/17 at 12:10 PM. E#3 stated that contraband searches are only completed upon admission, the first search is completed in the emergency department, and again on the unit.

5. The nurse (E#3) caring for Pt. #2 and Pt. #3 on 5/18/17 was interviewed on 5/22/17 at 1:00 PM. E#3 stated that Pt. #2 had been belligerent most of the evening. Pt. #2 threatened to hurt the staff and tried to throw a chair at a staff member. Security was called and Pt. #2 was taken to his room and given an injection to help calm him down. E#3 stated, "(Pt. #2) allowed us to give him the shot without a fight at 9:40 PM. The last time I saw him was around 10:00 PM.

6. A Patient Care Technician (PCT - E#4) on duty the night of 5/18/17 was interviewed on 5/22/17 at 1:40 PM. E#4 stated, "I was doing my regular rounds and when I got close to 467, I started to smell smoke. I saw the two patients from that room down the hall and they were walking back towards me. I asked them if they were smoking again and they said no. The patient opened the door to their room and we saw the mattress on fire. I tried to close the door again, but I couldn't. I then yelled for help and the fire alarm went on". E#4 stated that the evening before (5/17/17) there was a marijuana smell coming from room 467 and she called security to come up and check the area. Security came up and did not smell anything. E#4 checked the room for a lighter or matches and did not find any. Both patients in the room (Pt. #2 and Pt. #3) denied smoking. E#4 stated, "I was worried that these two patients were smoking again and that's what I smelled, but it was an actual fire".

7. The internal incident report dated 5/18/17 was reviewed on 5/22/17 and included, "Fire intentionally set room 467 ... Damage - Fire in room 467 - 4 East, extensive smoke damage.

8. The Senior Vice President of Quality and Compliance (E#6) was interviewed on 5/23/17 at 11:00 AM. E#6 stated, " I was told by the fire department that the fire was definitely arson". E#6 stated that the hospital administration believe a visitor might have brought in a lighter and given it to Pt. #2. The visitor log for the 4 east unit has been unable to be located since the fire.

9. The Vice President of Pt. Care (E#7) was interviewed on 5/23/17 at 1:35 PM. E#7 stated, "I interviewed the staff on duty on 5/17/17 and was told that security found a lighter in (Pt. #2's) room and it was removed". A report from security was unavailable. E#7 stated that precautions were not changed for Pt. #2 after finding the lighter.

Based on a life safety code complaint survey that was conducted on 5/22/17 it was determined by observations, staff interview, and document review that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on a life safety code complaint survey that was conducted on 5/22/17 it was determined by observations, staff interview, and document review that the facility failed to provide and maintain a safe environment for patients and staff. The facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.