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Based on interview and documentation review the facility failed to sufficiently take immediate action to ensure patients received care in a safe environment (A144). The cumulative effect of this practice resulted in the inability to ensure the safety of the all patients receiving services at this facility.

Based on documentation review and staff interview the facility failed to sufficiently take immediate action to ensure patients received care in a safe environment. This has the potential to affect all patients in the facility. The facility's census was 191.

Findings include:

Interview with Staff E completed on 02/24/16 at 9:15 AM revealed all life safety controls in place worked appropriately, dampers shut appropriately. The sprinkler released and extinguished the fire. The ER clean utility room where the fire occurred contains linens and a blanket warmer. A cauterizing tool was found in the trash in the clean utility room and thought to be ignition source. Staff E stated there is no policy requiring the clean utility room to be locked.

Review of the Protection Services Department Fire System Incident Report completed on 02/24/16 revealed a fire was detected in a clean utility room of the Emergency Department on 02/21/16 at 7:58 PM. The report revealed the Middleburg Heights Fire Department (MHFD) was dispatched, arrived and took over the scene. The report revealed staff followed the hospital patient evacuation protocol for an active fire. After the fire was contained, the hospital officers were advised by the Assistant Chief of the Local Fire Department the fire was going to be further investigated.

Interview with Staff J completed on 02/24/16 at 12:19 PM revealed action taken on 02/22/16 included 5 employees were placed on administrative leave during the ongoing fire investigation. No other documentation of immediate actions taken by the facility to ensure patient safety was available for review. Staff J stated the investigation is ongoing.