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Based on document review, video surveillance review, and interview, it was determined that the Hospital failed to ensure patient safety during a fire, and failed to ensure completion of room checks for contraband, both resulting in the risk for serious injury. As a result, the Condition of Patient Rights (42 CFR 482.13) was not met. This potentially affected all 12 patients on the 4W census as of 10/14/15.

Findings include:

1. The Hospital failed to ensure the Fire Safety Plan was implemented in accordance with Hospital policy. (A-144-A)

2. The Hospital failed to ensure room checks for contraband were completed in accordance with Hospital policy. (A-144-B)

An Immediate Jeopardy (IJ) and serious threat to patient safety was created from the cumulative effect of these systemic practices.

The immediate jeopardy began on 10/14/15 when Pt #1 started a fire in the 4W men's bathroom with a lighter (contraband item). During the course of the fire, the staff failed to remove 3 patients from the immediate area of the fire as they watched staff extinguish the fire; failed to activate the alarm system at the fire pull station; and failed to call the emergency line to report the location of the fire.

The Chief Medical Officer, Chief Nursing Officer, Vice President of Missions, Chief Financial Officer, Regional Quality Lead, Quality and Patient Safety Specialist, Director of Behavioral Health, Clinical Nurse Manager of 4W, Risk Specialist, Safety Officer, and Director of Support Services were notified of the immediate jeopardy at 3:50 pm on 10/21/15.

A. Based on review of documents, review of video surveillance, and staff interview, it was determined for 2 of 2 (E #1 and E #2) hospital employees who responded to a fire on the 4 West (4W) behavioral health unit, the hospital failed to ensure staff response was in accordance with policy. This potentially affected the safety of the 12 patients on the 4W census at the time of the fire, on 10/14/15.

Findings include:

1. The hospital policy entitled "Fire Response Plan" (effective 03/29/13) was reviewed on 10/19/15 and required, "...Method of staff response to a fire: 1. Rescue-Remove patients/persons from immediate danger...2. Alarm-Activate the nearest fire alarm box by pulling the handle/AND dial "1111" from any in-house telephone and state "CODE RED" and the exact location...3. Contain-Close doors and windows. Place wet linens under doors if time permits. 4. Extinguish-Extinguish very small fires with portable fire extinguishers. Evacuate the immediate area if you feel that you are in danger..."

2. The hospital's security surveillance video of the west/men's wing of 4W on 10/14/15 from 3:19 pm - 3:32 pm was reviewed on 10/20/15 at approximately 9:30 am with the Manager of Safety, Security and Communications (E #4). The video showed the following events:
3:19 pm: Pt #1 is walking down the hall, something falls from his pocket, and he picks it up and returns the item to his pocket.
3:20 pm: Pt #1 enters the men's bathroom (located on the west wing of the unit) and closes the door behind him.
3:21 pm: Pt #1 exits the bathroom, shuts the door behind him, something fell from Pt #1's pants, Pt #1 picks it up, walks down the west hall, and enters another patient's room (room 479).
3:22 pm: A patient (Pt #2) walks out of room 475 (located directly across the hall from the men's room), goes to the men's bathroom, opens the door, then walks towards the nurses' station and talks to E #1. E #1 and E #2 walk to the door of the men's bathroom. E #2 enters the men's bathroom for a couple of seconds. E #1 retrieves the fire extinguisher and enters the men's bathroom. Three patients are standing in the hall near the men's bathroom (approximately 4 feet from the bathroom with the fire) watching E #1 and E #2 respond to the fire.
3:23:20 pm: The fire doors close between the central area of the unit and the west/men's wing of the unit. (The fire doors separate the central area of the unit from the west wing)
3:24 pm: One of the fire doors opens, and five patients come from the west wing into the central area of the unit located on the safe side of the fire doors.

The video surveillance did not show the evacuation of patients, activation of the alarm system by staff using the fire alarm pull station, or containment of the fire prior to staff extinguishing the fire as required per policy.

3. On 10/19/15 at approximately 1:30 pm, an interview was conducted with E #1 (Behavioral Health Counselor). E #1 stated Pt #2 came out of the bathroom and said there was a fire in the bathroom. E #1 and E #2 (RN) went to the men's bathroom and found the fire. "There was a stack of paper towels on the floor on fire, and the flames were about 2 feet high. [E #2] tried to stomp out the fire while I went and got the fire extinguisher from the locked cabinet in the hall. Then I put the fire out with the extinguisher. [E #2] then called the emergency number for the fire." When the surveyor asked why staff chose to extinguish the fire before evacuating patients from the area or pulling the fire alarm, E #1 stated that it was in the bathroom, there were no patients in the bathroom, and the fire looked small enough to extinguish. When the surveyor asked E #1 if he had ever used a fire extinguisher prior to this event, E#1 said no.

4. During an interview with the 4W Nurse Manager (E #4) on 10/19/15 at approximately 2:00 pm, E #4 stated that E #1 and E #2 should have evacuated the patients, pulled the fire alarm, and called the emergency number before attempting to extinguish the fire.

B. Based on review of documents and staff interview, it was determined for 1 of 2 (4W) adult inpatient behavioral health units, the hospital failed to ensure the completion of room checks for contraband in accordance with policy. This potentially allowed the presence of contraband and endangered the safety of all patients on 4W.

Findings include:

1. The hospital policy entitled "Room Safety Check" (revised 04/2013) was reviewed on 10/20/15 and required, "...Room should be inspected at 10:00 am and 9:00 pm...Check for any hazardous items...Room checks will be documented on Safety Room Check Monitor Form...The rooms are checked for contraband by visual inspection..."

2. The 4W Safety Room Check forms for the month of October, 2015 were reviewed on 10/20/15. Documentation of room checks was missing for the following dates: 10/1 (am,pm), 10/2 (pm), 10/3 (pm), 10/4 (am), 10/5-10/6 (am,pm) 10/7 (pm) 10/8-10/9 (am,pm), 10/11 (am,pm), 10/12 (pm), and 10/14/15 (am).

3. The 4W variance report completed by E #1 (Behavioral Health Counselor) dated 10/14/15 was reviewed on 10/19/15 at approximately 12:00 pm and included, " [Pt #2] informed staff around 1520 [3:20 pm] that there was a fire in the men's bathroom. [E #1 - Behavioral Health Counselor (BHC)] along with [E #2 - RN] ran over to the bathroom. There was a fire on the bathroom floor next to the sink...[Pt #1] was the patient that was in the bathroom and started the fire. "

4. On 10/19/15 at approximately 1:05 pm, an interview was conducted with the Manager of 4 West (E #3). E #3 stated an interview was conducted with Pt #1 on 10/15/15 after reviewing the video surveillance which showed Pt #1 in the bathroom at the time the fire was started and the lighter falling out of his pant leg. Pt #1 admitted to starting the fire. Pt #1 told E #3 that he had brought the lighter on a previous admission. Pt #1 told E #3 that he had wrapped a lighter in tissue and hid it between his butt cheeks during the body check on admission. Pt #1 stated that the tissue held it in place even when he was asked to squat during the check. Pt #1 told E #3 that he had tied a little piece of string around the top of the lighter, took a piece of tape and stuck the string to the bed frame, and lowered the lighter under the frame. E #3 stated room checks were completed immediately following the incident on 10/14/15, and the lighter was found under the mattress on top of the bed frame in the unoccupied bed in room 479. E #3 stated room checks should have been done twice a day per policy.

The immediate jeopardy that began on 10/14/15 was not removed at the time of exit from the survey because the Hospital failed to complete re-education for staff on fire safety and room checks following this event.

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety portion of a complaint survey due to a fire was conducted on October 19, 2015 the surveyor found that the facility failed to provide and maintain a safe environment for patients, staff and visitors.

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

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety portion of a complaint survey due to a fire was conducted on October 19, 2015 the surveyor found that the facility failed to comply with the applicable provisions of the 2000 edition of NFPA 101 Life Safety Code.

See the life safety code deficiencies identified with K-tags on the CMS form 2567, dated October 19, 2015.