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The information reviewed during the unannounced complaint investigation survey on July 1, 2024, provided evidence that the facility failed to substantially comply with this Condition of Participation by failing to provide a safe environment for patients. A patient was able to obtain contraband (some type of lighter) and set fire to the facility that caused environmental damage and put all patients at risk for serious injury.
A discussion took place with the survey team and the facility's administrative staff regarding the survey team's concerns related to Patient's Rights on July 1, 2024, at 11:00 AM.
The Immediate Jeopardy was called at 11: 30 AM on July 1, 2024.
The facility submitted an acceptable Immediate Jeopardy Removal Plan at 5:35 PM on July 1, 2024.
The Immediate Jeopardy was removed on-site on July 1, 2024. Condition of Participation non-compliance remains.
The surveyor validated the Immediate Jeopardy Removal Plan was substantially implemented by education documentation, policy and procedure revisions, and interviews.
Cross reference
§482.13 (c)(2) Patient Rights: Care in a Safe Setting

Based on review of facility documents, tour, video footage, medical record (MR) and interviews with staff (EMP) it was determined the facility failed to maintain a safe setting for patients by not preventing a patient from accessing contraband (some type of lighter) which was used to start a fire. Prior to the fire the patient was found smoking on the nonsmoking premises and the facility failed to determine how the patient got the lighter or if more was accessible. In addition, the facility failed to follow their search policy to remove all contraband. The fire put all patients at risk for serious injury.
Findings:
Review on July 1, 2024, of facility policy, "Consumers Rights and Grievance and Appeal Procedure" dated December 2022, revealed "The purpose is to ensure that the rights guaranteed to consumers are safeguarded. ..."

Review on July 1, 2024, of facility policy "Searches of Visitors and Consumers" dated July 2022, revealed "Wernersville State Hospital maintains a safe, therapeutic environment free from materials which are counterproductive to recovery. ... Conducting searches for contraband or restricted items is done after all alternatives to insuring safety are exhausted ... Definitions: A. Contraband - Contraband shall include anything which would be illegal or dangerous in the possession of a consumer. Items identified below are illegal, dangerous independently, or a danger when mishandled in the hospital setting potentially jeopardizing the personal safety of consumers, employees, and visitors. B. Contraband Prohibited by the Facility - Neither consumers nor visitors may bring any of the following into the facility, unless otherwise approved by Administration: Matches, lighters, tobacco, tobacco products ... Each search must be explained to the affected consumer(s) and conducted only for probable cause. Consent is always requested. ... If the consumer refuses to be searched, the physician will be contacted. The physician will insure a search over objection is clinically indicated and specify the rationale for such as well as the type of search needed in a physician ' s order. Specific searches must be ordered by a physician by name of search, personal search, personal external body search, or living unit search. Searches are ordered for a single episode for a consumer at risk of harm to self or others. This order is time limited. The Nursing Supervisor is then contacted to secure approval from the CEO, designee, or Administrator-On-Call and to brief him/her regarding the need for the search over objection. ... VIII. Contraband Disposition - When facility staff discovers objects, devices, and substances which are taken from a consumer or visitor for health or safety reasons, the following steps must be followed: A. Documentation, Receipts and Reports. All searches and the results thereof must be documented. ... completion of an entry in the Interdisciplinary Progress Note covering: 1. Date & Time 2. Authorization 3. Specific Reasonable Cause 4. Natural/Type of Search 5. Conducted by 6. Consent obtained (if so, from whom, if not, why?) 7. Result of search ...

Tour of facility on July 1, 2024, at approximately 1:00 PM, revealed that building 35 (wing four) contained three patient rooms which had smoke and fire damaged from the fire that occurred in the facility on June 27, 2024. Wing four had windows boarded up and several large floor fans used to remove the smell of smoke. During the tour EMP 4 explained wing four requires clean up, reconstruction and the timeframe to restore wing four will take approximately 8 months.

Review of video footage on July 1, 2024, at approximately 11:00 AM revealed footage from June 27, 2024, starting at 1:45 PM and ending at 1:55 PM. The footage showed Patient (MR1) and staff moving throughout the hallway (wing four). The origin of the fire was observed. MR1 was walking to and from room private patient room. MR1 walked to and from room approximately four times in a row until smoke was noticed coming from the room. At that time, the unit began to evacuate.

Review on July 1, 2024, of MRI revealed the patient was re-admitted to the facility on May 20, 2021, with a primary diagnosis of schizoaffective disorder, bipolar type and a history of arson. The review of the annual "Psychiatric Evaluation" dated April 23, 2024, revealed the patient continued to exhibit behaviors of low moods, urinating in room on clothing, smoking and/or smelling of smoke and grand delusions of being a doctor. Patient was adherent to medications but declined workshop and similar activities. Review of "Interdisciplinary Progress Notes" revealed on May 29, 2024, the social worker met with the patient to go over the hospitals rules of not smoking. On June 4, 2024, the patient was witnessed smoking by security and the doctor was notified. No documentation or physician order was found in the MR that a search was conducted.

Further review of MR1 revealed the patient admitted to starting the fire that occurred on June 27, 2024. Note in MR1 states the patient admitted to fire starting due to anger related to not being able to smoke. The patient admitted to knowing and having full intent of fire spreading from personal bedroom. The patient stated "I was hoping it would. I was lighting the sheets and blankets on fire. I would rather be in jail." After the fire the hospital documented that they reduced privileges to limit the risk of further access to fire starting.

Interview on July 1, 2024, at approximately 11:15 AM with EMP1 revealed on June 4, 2024, patient was seen smoking on the side of building 9 which was witnessed by EMP2. In addition, patient was suspected of smoking on several other occasions.

Interview with EMP 3 at approximately 3:30 PM confirmed there was no official documentation or physician orders to show a search took place after the patient was found smoking and the facility did not follow their "Searches Of Visitors and Consumers" policy.