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Based on observations as referenced in the Life Safety report of survey completed November 19, 2018, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

Findings Included:

On Monday November 19, 2018 at approximately 12 Noon - 4:00 PM, This Life Safety Code (LSC) Complaint survey (Complaint Intake # NC00145541) was conducted as a result of a fire incident reported in room # OR -2 of the OR Suite (First floor). A fire occurred on 11/13/2018 at 1010, during a surgical procedure.

Based on Staff interview, Documentation available, and observation of the OR #2, the investigative findings are as follows:

1. Cause of fire : hospital staff failed to provide safe care in an oxygen enriched environment during a surgical procedure which included electrocautery which resulted in flashovers and pockets of fire which ignited the protective surgical apron on patient and heat damage to O2 mask - oxygen delivery equipment attached to patient. Additional details and Injuries to patient and one staff are covered in Health Survey findings tags.

2. The Fire was immediately extinguished by staff utilizing water and towels.

3. The fire did not generate enough heat to activate sprinkler system in the room, nor enough smoke to activate the smoke duct detector in the HVAC unit serving the room. (There was a smoke detector located in the corridor directly outside the room , but the corridor door was closed during the incident as required for surgical procedures).

4. The LSC deficient practice includes: During staff interview, staff on duty in the OR at time of incident stated that they did not believe the fire was significant and they did not need to implement the Fire Plan. The staff failed to follow their Fire Safety plan and the requirements of NFPA 101 LSC, 2012 ed Sections 19.7.2.1, 19.7.2.2, 19.7.2.3. as follows:

a. Removal of occupants directly involved with the fire emergency
b. Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff
c. Transmission of alarms to Fire Dept
d. Emergency phone call to Fire Dept

Reference : NFPA 101 LSC, 2012 ed, Sections 19.7.2.1, 19.7.2.2, 19.7.2.3.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 0711