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The hospital's Governing Body failed to oversee and ensure the safety of 1 of 4 sampled patients who sustained burns over 22% of her body (Patient #1). The Governing Body holds the ultimate responsibility for the hospital's compliance not only with the specific standards of the Governing Body Condition of Participation (CoP), but also with all of the CoPs.

Findings:

Cross Reference A0083. Based on interviews, record review, and review of hospital documents, the hospital's Governing Body failed to oversee and ensure the safety of 1 of 4 sampled patients, who was restrained and had cognitive decline, obtained a lighter, and set herself and her immediate surroundings on fire. The patient sustained burns over 22% of her body (Patient #1). This resulted in Immediate Jeopardy which began on February 3, 2022.

The implementation of the Hospital's Removal Plan for Serious Threat was verified by the survey team on February 18, 2022 at approximately 7:00 p.m., and included the following immediate actions:

Effective February 18, 2022, the majority of the Governing Body provided oversight and approval of the Plan of Correction.

Through February 17 and 18, 2022, members of the governing body revised policy #1475 "Patient Property and Record Inventory" for immediate use.

Effective February 18, 2022, members of the governing body approved the "Belongings Management for Patient Safety", for immediate implementation.

Effective February 18, 2022, an education brief was approved by members of Governing Body for distribution to clinical ream members for immediate completion prior to their work schedule.

The Governing Body is scheduled to review the new policy, "Belongings Management for Patient Safety", at their next meeting to determine if additional revision is needed.

The plan of correction to remove serious threat was verified by the survey team on February 18,
2022 at approximately 7:00 p.m.

Based on interviews, review of "Patient Property and Record Inventory" policy, review of hospital event report, patient medical record review, and review of the hospital's Bylaws, the hospital's Governing Body failed to oversee and ensure safety of 1 of 4 sampled patients, who was restrained and had cognitive decline, obtained a lighter, and set herself and her immediate surroundings on fire. The patient sustained burns over 22% of her body (Patient #1).

Findings:

Cross Reference to Condition of Participation A043. On 2/01/2022, patient #1 underwent surgery of an irrigation and debridement with removal of hardware left ankle and left femoral tibial bypass. Patient #1's post anesthesia care unit (PACU) Registered Nurse's (RN) note, dated 2/01/2022 at 8:05 PM, reflected that the patient was alert, oriented to person, disoriented to place, time, and situation with a Glasgow Coma Score (GCS) of 15. "The Glasgow Coma Scale (GCS) is used to describe the general level of consciousness in patients with traumatic brain injury (TBI) and to define broad categories of head injury. The GCS is divided into 3 categories, eye opening (E), motor response (M), and verbal response (V). The score is determined by the sum of the score in each of the 3 categories, with a maximum score of 15 and a minimum score of 3. . ." (Retrieved 2/23/2022, Medscape.com). On 2/01/2022 at 9:46 PM, the registered nurse documented that the patient had a GCS of 14, was confused, had poor safety awareness, was agitated, and had removed her post-surgical dressing.

A Physician's Progress note on 2/01/2022 at 11:31 PM read, "Pt. [patient] is very agitated and difficult to orient. Patient took off Aquacel dressings on left lower extremity. Need order for restraints, side rails times four, soft wrist times two, and vest. Also, PRN (as needed) medication for agitation."

A Vascular Physician's Progress note, dated 2/01/2022 at 11:27 PM, reflected concerns of a groin hematoma. The physician wrote, "Patient seen and evaluated at bedside with RN. Per report, patient has been agitated since she was transferred from PACU to her room. She subsequently ripped her left lower extremity Aquacel dressing off and was moving her left leg significantly. This is associated with the formation of a hematoma and possible arterial bleeding. Upon evaluation patient hemodynamically stable and agitated with a Glasgow score of 14. There is a hematoma (a pool of blood under the skin) of her left groin with no evidence of active bleeding currently. Pressure had been applied directly to the area prior to evaluation. Patient now in restraints. Palpable pulses and left lower extremity."

A Psychiatric Consultation for capacity note on 2/02/2022 at 12:08 PM read, "Diagnosis: Evaluation for capacity to make medical decisions, Hyperactive Delirium, Paranoia . . . Patient does not have medical decision-making capacity."

A hospital event report of 2/04/2022, reflected that on 2/03/2022 at 9:35 PM, ". . . staff nurses . . .shouted that there's a fire in [Patient #1's room]. Code Red was called overhead. All staff members ran to the room and stopped the fire which was contained to the patient's bed . . . Once the fire was extinguished, the nurses assessed the patient and notified [physician] stated that they would put in a consult for the burn team and that a physician would be up to assess the patient. The fire department came up and cleared the scene after assessing the situation. Security came up and cut off the patients locked restraints and confiscated a lighter from the patient's bed. Administration also came up and assessed the patient and the situation and the patient's belongings for any additional safety hazards."

Documentation revealed the patient sustained burns over 22% of her body which included the medial (middle) trunk full thickness, left upper arm full thickness, thigh anterior, right full thickness, and left-hand full thickness. At the time of the survey, the patient continued to be treated with ongoing care and surgical needs.

Review of hospital policy entitled "Patient Property and Record Inventory" #1475, read on page 2, "If the patient lacks mental capacity, has no family members present to control belongings, or is under a Baker Act [Florida Mental Health Act that allows for involuntarily psychiatric examination], the Team Member will inventory all belongings and secure valuables. Place all basic, non-essential small property in a belongings bag and attach a PILs label. (Patient identification label)."

Once it was determined by the psychiatric evaluation on 2/02/2022 that patient #1 did not have medical decision making capacity, the hospital staff failed to remove her personal items, inventory them, and store them away as directed. This resulted in the patient having her personal items in bed with her. Even though restrained, she was able to obtain a lighter from her purse in an attempt to burn off the restraints. This resulted in the bed, linens, and herself to be set on fire.

On 2/14/2022 at 1:10 PM, the Operations Manager of Risk Management and other risk managers agreed that staff did not remove patient #1's belongings after she had been determined to be incapacitated. They said patient #1 had somehow gained access to her purse in her bed while she was restrained, and an inventory of her belongings had not been done. At 3:10 PM, they stated the patient's purse was found in her bed and it was unknown how that happened as multiple staff members stated they did not give it to her and saw the purse on a table next to a chair out of patient #1's reach.

On 2/15/2022 at approximately 3:45 p.m., the Director of Security related after the fire, staff members also found a pocketknife, scalpel scissors, and tweezers in patient#1's purse. The pocketknife was given to security, and the others disposed of in the biohazard container.

During an interview on 02/17/2022 at approximately 7:30 p.m., the Chief Operating Officer (COO) and President of the hospital related they, members of the Governing Body, were directly responsible for the care and services in the hospital. The COO also stated there was "a gap" in that they "did not envision having to safeguard the patients from themselves". They stated the existing policy, "Patient Property and Record Inventory" regarding securing patient's valuables "If the patient lacks mental capacity . . . [staff] will inventory all belongings and secure valuables . . ." was not created nor meant to be used as a patient safety policy but rather a policy to protect patient's valuables/belongings such as watches and rings. They said employees were "without a policy to guide them" regarding patient safety.

A copy of the hospital Bylaws presented by the Director of Risk Management, dated 10/18/2017, on page 1 read, "The Board of Directors of the Corporation shall maintain oversight of the functioning of the ODSA Board (Orlando Regional Medical Center and including other sites) and shall retain ultimate authority over and responsibility for the oversight of the Medical Staff, quality and regulatory issues to be considered by the ODSA Board."

The hospital failed to ensure that Patient #1 received care in a safe setting as evidenced by failing to follow the facility's policy, regarding inventory of her belongings and securing valuables; when it was determined by the psychologist on 2/02/2022 at 12:08p.m., the patient did not have medical decision making capacity.

The hospital failed to ensure patient rights to receive care in a safe setting, which resulted in 1 of 4 sampled patients who was incapacitated and restrained, obtained a lighter, set fire to herself, bed, mattress, linens, and sustained burns over 22% of her body (Patient #1). The hospital's failure to follow protect the patient placed patient #1 and other patients with similar conditions at risk for serious harm, injury, or death. This resulted in Immediate Jeopardy which began on February 3, 2022.

Findings:

Cross Reference A0144. Based on interview and record review, the hospital failed to protect 1 of 4 sampled patients from physical harm by allowing the restrained incapacitated patient to obtain a lighter from her purse and set herself on fire (Patient #1). The implementation of the Hospital's Removal Plan for Serious Threat was verified by the survey team on February 18, 2022 at approximately 7:00 p.m., and included the following immediate actions:


Effective February 17, 2022, at 3:30 p.m., all incoming patient transfers who enter through the
Copeland entrance will have their belongings scanned by security. This was the only entrance
point that did not have screening in place and was the point of entry for the patient under review.

Effective February 18, 2022, the draft patient safety policy, "Safe Patient Belongings Management" was approved for implementation. Patients who lack capacity will have belongings and valuables inventoried and sequestered by security per the new policy.

Effective February 18, 2022, policy #1475 "Patient Property and Record Inventory was revised.

Effective February 18, 2022, the new policy was reviewed with Orlando Regional Medical Center (ORMC) Executive Leadership and Nursing Administrators by Chief Nursing Officer.

On February 18, 2022, distribution of the education was completed through email, safety huddles and face to face instruction by nursing leaders.

Effective February 18, 2022, by 4:00 p.m., an education brief will be loaded into the learning
system and assigned to all clinical leaders and direct care personnel in the acute care hospital for
significant completion within 14 days. Compliance will be electronically monitored. Team members who are not scheduled to work during the education period, will be required to complete education upon return to work.

Based on interview and record review, the facility failed to provide safe care and services to 1 of 4 sampled patients who was in a secure and protected environment (Patient #1). Patient #1, who was restrained and had cognitive decline, obtained a lighter, and set herself and her immediate surroundings on fire. The patient sustained burns over 22% of her body. This resulted in Immediate Jeopardy which began on February 3, 2022 and was removed on February 18, 2022.

Findings:

Cross Reference to Condition of Participation A115. On 2/01/2022, patient #1 underwent surgery of an irrigation and debridement with removal of hardware of the left ankle and left femoral tibial bypass. The post anesthesia care unit (PACU) registered nurse's (RN) note, dated 2/01/2022 at 8:05 PM, reflected that the patient was alert, oriented to person, but disoriented to place, time, and situation. RN documentation on 2/01/2022 at 9:46 PM reflected that patient #1 was confused, had poor safety awareness, was agitated, and had removed her pos surgical dressing.

A physician's progress notes on 2/01/2022 at 11:31 PM read, "Pt. [patient] is very agitated and difficult to orient. Patient took off Aquacel dressings on left lower extremity. Need order for restraints, side rails times four, soft wrist times two, and vest. Also, PRN (as needed) medication for agitation."

A vascular physician's progress note dated 2/01/2022 at 11:27 PM reflected concerns of a groin hematoma [accumulation of blood]. The vascular physician wrote, "Patient seen and evaluated at bedside with RN. Per report, patient has been agitated since she was transferred from PACU to her room. She subsequently ripped her left lower extremity Aquacel dressing off and was moving her left leg significantly. This is associated with the formation of a hematoma and possible arterial bleeding. Upon evaluation patient hemodynamically stable and agitated with a Glasgow score of 14. There is a hematoma of her left groin with no evidence of active bleeding currently. Pressure had been applied directly to the area prior to evaluation. Patient now in restraints. Palpable pulses and left lower extremity."

A psychiatric consultation for capacity was completed on 2/02/2022 at 12:08 PM and read, "Diagnosis: Evaluation for capacity to make medical decisions, Hyperactive delirium, Paranoia. Recommendations . . . Patient does not have medical decision making capacity.

A hospital event report of 2/04/2022, initiated 2:25 a.m., reflected that on 2/03/2022 at 9:35 PM, ". . . staff nurses saw a flame that reflected on the glass side window and shouted that there's a fire in [Patient #1's room]. Code Red was called overhead. All staff members ran to the room and stopped the fire which was contained to the patient's bed. The fire alarm and sprinklers never went off in the patient's room." Once the fire was extinguished, the nurses assessed the patient and notified the physician and stated they would put in a consultation for the burn team and that a physician would assess the patient. The fire department came up and cleared the scene after assessing the situation. Security came up and cut off the patient's locked restraints and confiscated a lighter from the patient's bed. Administration representatives also came up and assessed the patient, the situation, and the patient's belongings for any additional safety hazards."

Documentation revealed the patient experienced 22% of burns to her body which included her medial [middle] trunk full thickness, left upper arm full thickness, thigh anterior, right full thickness, and left hand full thickness.

Review of hospital's policy entitled "Patient Property and Record Inventory" page 2 read, "If the patient lacks mental capacity, has no family members present to control belongings, or is under a Baker Act [Florida Mental Health Act that allows for involuntarily psychiatric examination], the Team Member will inventory all belongings and secure valuables. Place all basic, non essential small property in a belongings bag and attach a PILs label. (Patient identification label)."

The patient was incapacitated, and the hospital did not secure her personal items, inventory them, and did not remove them from the room or bag and store them away as directed. The lack of action resulted in the patient having her personal items in bed with her. Even though restrained, she was able to obtain a lighter from her purse in an attempt to burn the restraints off herself, and caught the bed, linens, and herself on fire.

Hospital documentation revealed patient #1 experienced 22% of burns to her body which included her medial [middle] trunk full thickness, left upper arm full thickness, thigh anterior, right full thickness, and left hand full thickness. The patient continues to be treated with ongoing care and surgical needs at the time of survey exit.

On 2/14/2022 at 1:10 PM, the Operations Manager of Risk Management and other risk managers agreed that staff did not follow the hospital policy because they did not remove patient #1's belongings after she had been determined to be incapacitated. They said patient #1 had access to her purse in her bed while she was restrained, and an inventory of her belongings was not done.

On 2/14/22 at 3:10 PM, the Operations Manager of Risk Management and other risk managers stated the patient's purse was found in her bed and it was unknown how that happened as multiple staff members stated they did not give it to her and saw the purse on a table next to a chair out of her reach.

On 2/17/2022 at 3:15 PM, the Director of Security related that staff members also found a pocketknife, scalpel scissors, and tweezers in patient #1's purse. The pocketknife was secured and given to security, and the others disposed of in a biohazard container. The hospital failed to ensure that Patient #1 received care in a safe setting as evidenced by failing to follow the facility's policy, regarding inventory of her belongings and securing valuables, when it was determined by the psychologist on 2/02/2022 at 12:08 p.m., the patient did not have medical decision making capacity.

Failure to provide a safe environment for patient #1 resulted in the patient obtaining a lighter from her purse and setting herself and the immediate environment on fire which resulted in disfigurement, additional surgeries, delayed healing of her original medical problems, prolonged, her hospital stay, physical pain and mental anguish to the patient.