HospitalInspections.org

Based on observation, interview, review of incident and medical record documentation for 1 of 1 patient who smoked while receiving oxygen therapy in the hospital (Patient 3), review of education/training records for 18 of 18 employees (Employees 1-18), review of education/training records for 2 of 2 medical staff (Staff 19 and 20), review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to ensure the provision of safe and appropriate care to patients in the hospital in a manner that complied with all Conditions of Participation.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A-0115 under CFR 482.13 - CoP: Patient's Rights.

2. Refer to the findings cited at Tag A-0263 under CFR 482.21 - CoP: Quality Assessment and Performance Improvement.

3. Refer to the findings cited at Tag A-0700 under CFR 482.41- CoP: Physical Environment.

Based on observation, interview, review of incident and medical record documentation for 1 of 1 patient who smoked while receiving oxygen therapy in the hospital (Patient 3), review of education/training records for 18 of 18 employees (Employees 1-18), review of education/training records for 2 of 2 medical staff (Staff 19 and 20), review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to ensure each patient's right to receive care in a safe setting.
* The hospital failed fully develop and implement policies and procedures to ensure patients were managed, supervised and prevented from accessing smoking supplies and ignition sources, and prevented from smoking in the hospital.
* Patient 3 was on six or seven liters oxygen administered by nasal cannula and the hospital failed to prevent the patient from accessing smoking supplies and ignition sources in their room. The patient smoked in their room under these conditions and was harmed when a fire ignited. The fire caused the patient serious burn injuries including third degree burns to face, right ear, right shoulder, and right pectoral area; and second degree burns to left hand. The patient had been non-compliant with the hospital's "Tobacco Free Campus" policy at least three times prior to this event, and the hospital failed to take effective preventive actions, including those required by hospital policy.
* The hospital failed to conduct thorough, complete, and timely investigations and follow up actions of at least three smoking and smoking related incidents involving Patient 3 to ensure they did not recur.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A-0144 and Tag A-0145 under CFR 482.13(c)(2) and (c)(3) - Standard: Privacy and Safety.

2. Refer to the findings cited at Tag A-0709 under CFR 482.41- CoP: Physical Environment.

Based on observation, interview, review of incident and medical record documentation for 1 of 1 patient who smoked while receiving oxygen therapy in the hospital (Patient 3), review of education/training records for 18 of 18 employees (Employees 1-18), review of education/training records for 2 of 2 medical staff (Staff 19 and 20), review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to fully develop and implement P&Ps that ensured patients' rights were recognized, protected and promoted, and the right to receive care in a safe setting as follows:
* The hospital failed fully develop and implement policies and procedures to ensure patients were managed, supervised and prevented from accessing smoking supplies and ignition sources, and prevented from smoking in the hospital.
* Patient 3 was on six or seven liters of "high flow" oxygen administered by nasal cannula and the hospital failed to prevent the patient from accessing smoking supplies and ignition sources in their room. The patient smoked in their room under these conditions and was harmed when a fire ignited. The fire caused the patient serious burn injuries including third degree burns to face, right ear, right shoulder, and right pectoral area; and second degree burns to left hand. The patient had been non-compliant with the hospital's "Tobacco Free Campus" policy at least three times prior to this event, and the hospital failed to take effective preventive actions to prevent this from recurring, including those required by hospital policy.

Findings include:

1.a. The P&P titled "Patient Rights & Responsibilities," dated last revised "09/2020," was reviewed and reflected "Each patient has a right to ... Receive care in a safe setting ... Be free from all forms of abuse or harassment ... General health care facility policies and procedures, which involve all employees, are developed to ensure the protection of the patient's rights ..."

1.b. The P&P titled "Tobacco Free Campus," dated last revised "01/2021," was reviewed and reflected:
* "It is the policy of CHI Mercy Health that the Hospital owned or leased buildings and properties are tobacco-free zones, including the vehicles parked on Hospital owned or leased properties ... Smoking or otherwise using tobacco or tobacco-like products (including but not limited to cigarettes, electronic cigarettes, cigars, chewing tobacco, snuff, pipes, snus, etc.) on company time or property is prohibited. This includes emerging tobacco product or simulated smoking device ... It is the responsibility of administration, department leaders, medical staff leaders, and all staff to enforce this policy."
* "Patients & Visitors ... Patients and their family/significant other(s) shall be informed during the admitting and scheduling process of the hospital's Tobacco Free Campus policy ... Physicians and hospital staff are encouraged to anticipate the patient's needs for nicotine replacement or other therapies ... The attending physician may order nicotine replacement or other therapies (i.e. lozenges or patches) to facilitate management of nicotine withdrawal symptoms."
* "Safety Precautions ... Individuals who violate the tobacco free policy in the hospital or at an entrance are jeopardizing the health and safety of themselves, and other patients, visitors, and staff ... Patients who violate this Tobacco Free Campus policy will kindly and firmly be re-advised of the safety risks involved. They will be counseled and it will be documented that if they violate the policy a second time, they risk being discharged against medical advice ... The physician is consulted if a patient violates the policy AND puts self or others at significant risk of injury (e.g. smoking near oxygen). The physician and care team will develop an appropriate plan of care to prevent harm to patient and others ... Security may be contacted if necessary to secure a safe environment or assist in enforcing this policy with visitors and patients."
* "Documentation ... All patients who identify as smokers on admission are oriented and instructed on the hospital's policy Tobacco Free Campus policy ... An incident involving patient non-compliance with the policy should be documented in the medical record and staff must follow hospital incident reporting procedures. The documentation should include ... The observation and/or facts relating to the non-compliant behavior ... The patient instruction about hospital policy and the associated risks and hazards of smoking ... The patient agreement to comply with the policy, and understanding the associated consequences of discharge from the hospital ... The removal of the tobacco products, matches, or lighters due to unsafe patient conditions. The personal items will be given to a family member/significant other to take home or returned at discharge ... Notification to visitors/family of the associated hazards and consequences of non-compliance to the policy ..."
The P&P was unclear and not fully developed. Examples include:
- The P&P was not clear when during the admitting process patients would be informed of the hospital's Tobacco Free Campus policy, and who was responsible to carry this out. The P&P did not stipulate whether patients were informed orally or in writing, or both. The P&P was not clear what steps would be taken to ensure the patient and others were safe if the patient did not agree to comply with the policy during the admitting process.
- The P&P states "if they violate the policy a second time, they risk being discharged against medical advice." It was not clear how patients would be supervised, monitored and kept safe if they were not discharged following a violation. For patients who were discharged, it was not clear how the patient and others would be kept safe from the time it was decided the patient would be discharged until the time they left the hospital's "tobacco-free zones."
- The P&P includes "The removal of the tobacco products, matches, or lighters due to unsafe patient conditions." It was not clear how this would be carried out, who was responsible, and how patients would be supervised, monitored, and kept safe if they refused removal or refusal could not be ensured. It was not clear where smoking supplies should be kept after removal if not "given to a family member/significant other to take home."
- The P&P did not describe measures security would take to "secure a safe environment" and "assist in enforcing this policy."

1.c. The P&P titled "Fire Safety Management Plan," dated effective "05/2020," was reviewed. It reflected:
* "Purpose ... The Fire Safety Management Plan manages and evaluates fire safety risks and activities to provide a safe, effective, and compliant environment ..."
* "Objectives ... Comply with fire safety-related regulatory agency standards and state and federal laws and regulations ... Develop, monitor, and enforce current fire safety practices, education, and training as appropriate ..."
* "Safety/Security Manager ... Focuses on safe work practices ... Has intervention authority to stop conditions that pose an immediate threat to life or property ..."
* "Environment of Care Committee ... Recommends relevant policies, standards, and education to improve the safety of the environment ..."
* "Department Manager ... Hold their employees accountable for following department and hospital fire safety procedures, policies, and/or practices ... Identify and correct, or notify the Safety/Security Manager of the fire safety related deficiencies within their area."
* "Employees ... Are accountable for following department and hospital fire safety related procedures, policies, and/or practices ... Are required to meet regular education requirements ... Are responsible for immediately reporting unsafe fire safety related conditions or deficiencies to their supervisor, the Safety/Security Manager, or Director of Facilities."
* "Safety Management Activities ... various tools and methodologies may be used to evaluate risk ... active risk assessments (e.g., incident and accident investigations ... root cause analysis, etc.) are used to identify trends for which corrective action is needed."

1.d. The P&P titled "Risk Management," dated effective "12/2020," was reviewed. It reflected:
* "The Risk Management program, for Mercy Medical Center (MMC), has been designed as a part of the coordinated quality improvement program for the improvement of quality of healthcare services provided to protect patients, staff members and visitors from inadvertent injury ... The Risk Management Plan (RM Plan) is an integral part of the quality improvement program which provides for ... Mitigating potential risk to patients, employees, providers, volunteers, visitors, and the organization ... Continuously improving the safe and effective patient care ... Providing a safe environment for patients, employees, providers, volunteers, visitors, and the organization ... The Risk Management Program supports the philosophy that proactive risk mitigation is the responsibility of each of the members of the team; leadership, providers, volunteers and staff are essential for an efficient and effective risk management program leading to optimal outcomes related to patient and work force safety ..."
* "Principles of the Plan provide the foundation for developing key policies and procedures for day-to-day risk management activities, including ... Reporting and management of adverse events and near misses through an effective incident reporting system, including ... Event investigation, root-cause analysis, and follow-up ... Trend analysis of events, near misses ..."
* "Governing Body Leadership ... The governing board is committed to promoting the safety of all patients, visitors, employees, volunteers, and other individuals ... The governing body entrusts leadership and management teams with the responsibility for implementing performance improvement and risk management strategies ..."

2. An interview was conducted on 06/28/2023 at ~ 1400 with the CCO/CNO, RM, UD and other hospital staff. During the interview staff confirmed that a fire incident involving Patient 3 occurred in the Surg/Peds Unit on 06/23/2023. The patient was smoking in their room while receiving "high flow" oxygen therapy by NC. The following information was provided about that incident:
* The patient presented to the hospital's ED for heel pain. Just prior to arrival the patient had been evicted from "assisted living" for smoking in their room.
* On ~ 06/18/2023, the patient was admitted to the hospital's Medical Unit and was waiting for surgery when staff found the patient smoking in their room. Hospital staff told the patient they could not smoke and the patient left the hospital AMA.
* The patient returned to the hospital's ED on 06/19/2023 and was admitted to the hospital.
* On 06/21/2023, the patient was agitated and told staff they wanted to smoke. Staff went into the patient's room and the patient had cigarettes and a lighter in their hand. The patient "relinquished" those and staff put them in a locked box.
* On 06/23/2023 at around noon, the patient told the nurse they wanted to smoke. The patient was on 6L "high flow" oxygen by NC. The physician ordered the patient's Nicotine patch strength to be increased. Later the same day a nurse smelled smoke and found the patient screaming with their "oxygen tubing in their lap trying to tap a fire out on [their] lap." The patient's face was blackened, and staff took the patient to ICU where they were intubated and transferred to another hospital's burn unit for treatment of their injuries.
* After the fire incident, staff found a sweater in the patient's room with matches, loose tobacco, and smoking filters in the pocket.
* The hospital had initiated, but not completed an investigation of the fire incident and had already identified some gaps. The RM stated the investigation was "a work in process."

3.a. The Surg/Peds Unit where the incident involving Patient 3 occurred was toured with the COO/CNO, UD, and other hospital staff on 06/28/2023 beginning at 1050. The following observations were made:
* The unit was closed, and large industrial fans and hydroxyl generators were observed in the halls.
* The unit had approximately 22 rooms. No patients were observed in the unit.
* Room 209 where the fire incident involving Patient 3 occurred had plastic wrap with red tape attached to the entry door. The room had been cleaned following the fire. The bed, privacy curtain, overbed table, and other furniture and equipment typically seen in an inpatient room had been removed. Staff present at the time of the observation stated the furniture had been taken outside after the fire due to fire damage.
* Observation of the wall where the head of the bed would normally be positioned revealed the wall mounted oxygen flow meter and medical air flow meter had been removed.
* No signs or other information were observed posted or otherwise visible in Room 209 or elsewhere in Surg/Peds Unit that reflected the hospital's Tobacco Free Campus policy, or risk of smoking in the hospital including near oxygen sources.

3.b. During interview with staff present 06/28/2023 at the time of the observations in finding 3.a. the following information was provided:
* The UD stated the Surg/Peds Unit was an adult and pediatric post-surgical unit. When the fire incident occurred, the entire unit was closed and currently remains closed because smoke came out into the halls and there were concerns with air quality. The UD stated at the time of the incident there were 9 adult patients on the unit. Patient 3 was taken to ICU, and all other patients on the unit were relocated to other units because of heavy smoke from the fire. The UD stated they did not know if staff checked the patient's room for smoking supplies or asked the patient if they had any smoking supplies before the fire incident.
* The COO/CNO stated the patient was actively smoking in their room at the time of the fire incident and the smoke was so thick after the fire started that staff who responded had a hard time seeing the patient. The COO/CNO confirmed there were no signs posted in Room 209 or anywhere else in Surg/Peds Unit that described the hazards of smoking while receiving oxygen therapy.

3.c. On 06/28/2023 at 1120, observation of items removed from Room 209 after the fire revealed:
* The items had been taken to an area outside of the hospital building and included a mattress, bed linens, pillow and a vinyl/polyester patient recliner chair.
* The mattress was charred along the left side and portions had black and tan, irregular shaped areas that looked like they had melted. A fitted sheet on the mattress had large areas of black and brown char and holes along the left side.
* Another sheet and a cloth draw sheet, both rumpled up were observed on top of the mattress. The sheet had tan, irregular-shaped burned areas.
* A pillow with a pillowcase on it were observed. One end of the pillow and pillowcase were black and tan, and charred-looking. The cover on the pillow looked like it had melted and black charred pillow stuffing was exposed.
* The left armrest and left leg rest on the patient recliner chair had whitish-gray powdery looking areas, gray charred areas, and other areas that looked like they had melted. Hardware on the left side of the recliner had black charred areas.

4. Review of the medical record and the hospital's internal investigation documentation reflected Patient 3 was a known long-time smoker with repeated episodes of smoking in the hospital while on oxygen therapy. The documentation revealed the patient was not supervised, managed, and prevented from smoking in accordance with hospital P&Ps. An explosion and fire occurred while the patient was smoking in their room while receiving "high flow" oxygen therapy, and the patient sustained injuries including second and third degree burns to face, chest and other body areas; and required intubation and emergent transfer to a burn unit at another hospital for treatment of their injuries.

4.a. The medical record of Patient 3 reflected:
* The patient presented to the ED on 06/15/2023 at 1607 for complaints of left foot edema and infection.

* RN documentation dated 06/15/2023 at 2132 on a "Mandatory Health Screen" reflected:
- "Smoking status/Current Every Day Smoker + Tobacco Use: 1/2 PPD ..."
- "Patient notified of Mercy's tobacco-free campus policy and nicotine replacement offered?" followed by a blank space.

* RN documentation date 06/15/2023 at 2155 reflected "... patients [sic] O2 is 86 on room air ... Provider gave order [to] place patient on 2L NC.

* RN documentation dated 06/15/2023 at 2315 reflected "Pt desated [sic] to 84% on RA ... Pt placed on 4L NC ..."

* Physician H&P notes dated 06/16/2023 at 0000 reflected "wheelchair bound ... notably short of breath, wheezing, and hypoxic requiring 4 L oxygen via nasal cannula, which [they] normally [don't] require ... smokes about half pack cigarettes a day ..."

* RN documentation dated 06/16/2023 at 0100 reflected "... [SpO2] 85% and cannula noted to be out of [patient's] nose. Cannula replaced and pt [SpO2] up to 97% on 5L so titrated down to 3L by NC."

* Physician notes dated 06/16/2023 at 0113 reflected "Smokes about half pack cigarettes a day ... saturations about 93% on 4 L oxygen via nasal cannula ... Assessment ... lower extremity cellulitis with a left heel ulceration and osteomyelitis ... Also noted to be dyspneic with acute hypoxic respiratory failure ..."

* The record reflected patient was admitted to the Medical Unit on 06/16/2023 at 0118.

* RN documentation dated 06/16/2023 at 0151 on a "Health Habits Screening" reflected:
- "Tobacco ... Unable to assess due to cognitive impairment? N"
- "Used tobacco products in the last 30 days? Y ... Tobacco Use/ Current Every Day Smoker + ..."
- "Pack/Day: 1/1 Number of Years: 61 ... Cigarette Use/Daily ..."
- "Receptiveness to Tobacco Counseling/ Would you like to receive a call from the Oregon Quit Line? +"
- "Contact Phone:" followed by a blank space.
- "Best Time to Call:" followed by a blank space.
- "Consent to provide info to Quit Line?" followed by a blank space.
- "Tobacco Cessation Information Given?" followed by a blank space.
- "Patient notified of Mercy's tobacco-free campus policy and nicotine replacement offered?" followed by a blank space.

* RN documentation dated 06/16/2023 at 0304 reflected "... new admit from the ED ... Wheelchair bound ... On 2L O2 NC [SpO2] 89-90% and room air baseline ..."

* RN documentation dated 06/16/2023 at 1933 reflected "Recently evicted from [assisted living] ... Currently on IV steroids for respiratory distress. Patient new to oxygen ..."

* RN documentation dated 06/17/2023 at 1739 reflected "Shift Summary [Patient] smoked tobacco in [their] room this morning. [Patient] was reminded that this is not allowed at MMC, [patient] gave [their] cigarettes to be kept safe in [their] medication drawer until discharge ... On 2L O2 NC ..."
There was no documentation that reflected the RN informed the patient of the safety risks involved with smoking while receiving oxygen.
There was no documentation that reflected the RN notified the physician that the patient was smoking.
There was no documentation that reflected the RN informed the patient that if they violated the hospital's tobacco free campus policy, they risked being discharged AMA.

* RN documentation dated 06/18/2023 at 1431 reflected "... [Patient] continues to be short of breath ... On 2L N/C O2 ..."

* A document dated 06/18/2023 at 1530 titled "Release From Responsibility For Discharge Against Medical Advice" reflected:
- "This is to certify that I, [followed by a blank space], a patient in Mercy Medical Center, Inc., am being discharged against the advice of the attending physician ..."
- The document was signed by two RN witnesses.
- The document was not signed by the patient or patient representative, and there was no documentation that reflected why it was not signed.

* Physician discharge summary notes dated 06/18/2023 at 1536 reflected "... on 2 liters of oxygen and has some cough ... Later in day I was called that patient was leaving AMA. This was due to being noted to be smoking in room despite warnings and [patient] advised by nursing of fire risk with oxygen and hospital policy. Nursing staff felt unsafe with patient having access to [patient's] wheelchair with smoking materials and they requested to lock up [patient's] wheelchair and [patient] declined and left AMA."

* RN documentation dated 06/18/2023 at 1620 reflected "... Pt left AMA ... Charge nurse and house supervisor involved when [patient] was smoking in [their] room wearing oxygen. [Patient] was [sic] also had alcoholic beverage in [their] room ... Charge nurse politely requested pt to let [their] personal belongings be put in a locked secure place under security but [patient] declined ... [patient] left medical unit at 1610 ..." Although an AMA form had been initiated on 06/18/2023 at 1530 due to the patient smoking in their room and refusal to relinquish their smoking supplies, there was no documentation that reflected the patient was supervised, monitored or otherwise ensured they would not smoke until after they left the hospital at or around 06/18/2023 at 1610, nearly 40 minutes later.

* Review of care plan and patient teaching documents did not include the patient's risk for smoking in the hospital, including risk of smoking while receiving oxygen therapy. There were no goals and individualized interventions based on an assessment of the patient's smoking risk to prevent harm to the patient and others. The only reference related to smoking was a "Patient/Family Education" document dated 06/18/2023 at 1248 that reflected:
- "Identified Educational Needs on Admission/Diabetes ... Specific Content: Diet, Avoiding Candy, Avoiding Smoking"
- "... Readiness Learn ... Uninterested"
- "... Understanding ... Moderate Understanding"
- "... Outcome ... Learner Verbalized"

The medical record contained:
* No nursing or other documentation that reflected staff informed the patient of the hospital's Tobacco Free Campus policy during the admitting process as required by hospital policy.
* No nursing documentation that reflected the patient, who was receiving oxygen therapy, was advised of the safety risks involved with smoking while receiving oxygen, including fire in accordance with hospital policy.
* No nursing documentation that reflected the physician was notified the patient was smoking in accordance with hospital policy.
* After the patient was found smoking in their room with oxygen on 06/17/2023 in the "morning," no documentation that reflected the patient was counseled that if they violated the hospital's tobacco free campus policy, they risked being discharged AMA in accordance with hospital policy.
* No documentation that reflected what ignition source (e.g., lighter, matches) the patient used to smoke and there was no documentation that reflected those were removed or security was contacted to assist with removal if needed, in accordance with hospital policy.
* No documentation that reflected the physician and care team developed a care plan that addressed the patient's smoking and associated safety risks, as required by hospital policy.
* The medical record lacked observations and facts related to the patient's non-compliant smoking behavior in accordance with hospital policy. For example:
- RN documentation dated 06/17/2023 at 1739 reflected "[Patient] smoked tobacco in [their] room this morning. [Patient] was reminded that this is not allowed at MMC, [patient] gave [their] cigarettes to be kept safe in [their] medication ... On 2L O2 NC ..." It was not clear what time in the morning the patient was smoking in their room, what time the patient was reminded this was not allowed, and what time the patient gave their cigarettes to be kept safe. It was not clear what aspects, if any, of the hospital's policy the patient was "reminded" about. It was not clear what "reminded" meant as this infers the patient was talked to previously. There was no documentation that reflected the patient's response when informed smoking was not allowed in the hospital, including if the patient agreed or did not agree to comply.
- Physician notes dated 06/18/2023 at 1536 reflected "... Later in day I was called that patient was leaving AMA ... due to being noted to be smoking in room despite warnings ... [patient] advised by nursing of fire risk with oxygen and hospital policy. However, it was unclear when the patient was "warned" and what they were warned about. It was also unclear when the patient was "advised by nursing of fire risk with oxygen and hospital policy" as there was no nursing documentation that reflected the patient was advised of those.

4.b. During interview and review of the medical record with CIC on 06/29/2023 at 1305, CIC confirmed:
* The patient was identified as a long time smoker on admit and there was no nursing or other documentation that reflected staff oriented and instructed the patient on the hospital's Tobacco Free Campus policy during the admitting process.
* There was no nursing documentation that reflected the patient was informed of the risks of smoking while receiving oxygen therapy, including risk of fire at the time this occurred in the "morning" on 06/17/2023 or at any other time.
* There was no nursing documentation that reflected the physician was informed that the patient was smoking in their room at the time this occurred in the "morning" on 06/17/2023 or at any other time.
* There was no "care team" or nursing care plan that addressed the patient's risk for smoking in the hospital, including risks related to smoking while receiving oxygen therapy.

4.c. Review of incident documentation regarding Patient 3 reflected that on 06/18/2023 at 1618 the patient was "... found to be smoking in room for second time. Patient advised that [their] belongings and powerchair would need to be secured in storage both to keep patient and staff safe as patient was smoking with oxygen ... Patient stated [they were] unwilling to do this and would prefer to leave AMA. Risks explained to patient. Patient stated understanding. Patient pleasant and cooperative and left AMA ..."
* "Did a deviation from performance standards by staff lead to this event? No"
* "Additional details regarding deviation" followed by "Pt doesn't not [sic] want for [sic] follow basic safety rules."
* "Department Reviewer Comments/Actions ... This patient has made poor choices and has left AMA previously as well."
* "Reviewer Follow-Up ... Contributing Factors ... Patient/Family - Failure to Follow Plan of Care"
* "Patient Harm Determination ... To be Determined"
* "Level of Severity" followed by a blank space.
* "Preventability" followed by a blank space.
* "Was this a good catch?" followed by a blank space.

The documentation lacked a clear, complete, and thorough investigation. For example:
The documentation reflected the patient was found smoking in their room a "second time." There was no investigation regarding the previous incident of smoking in their room on 06/17/2023 in the "morning," including time that occurred, potential injuries, smoking supplies/ignition source used, whether the patient was receiving oxygen therapy, or any other information. There were no staff interviews or other information that reflected whether smoking supplies had been observed in the patient's room before the first smoking incident, and if so, what actions were taken or should have been taken to address those. There was no documentation of follow up actions taken or planned.

Regarding the "second" smoking incident, there was no investigation that reflected:
* The specific smoking supplies, including ignition source the patient used to smoke in their room.
* Whether the patient was harmed as a result of the incident. The documentation reflected "Patient Harm ... To be Determined."
* Whether the patient was informed of the hospital's Tobacco Free Campus policy, including during the admitting process in accordance with hospital policy.
* Whether there was a care plan that addressed the patient's smoking in the hospital, including risks while receiving oxygen therapy. Although the documentation reflected a contributing factor was "Patient/Family - Failure to Follow Plan of Care," it was not clear what aspects of the plan of care were not followed. Refer to finding 3.a. that reflected there was no plan of care that addressed the patient's smoking non-compliance.
* The incident was evaluated for compliance against applicable hospital P&Ps. For example, P&Ps related to incident reporting and investigation, tobacco free campus, and care planning.
* Additional follow up actions taken or planned.
* Whether abuse and neglect were ruled out.
Due to the failure to conduct a complete, thorough and timely investigation and follow up actions, there was no assurance similar incidents involving Patient 3 or other patients would not occur.

4.d. During interview and review of incident documentation in finding 4.c. with the RM on 06/28/2023 at 1630, the RM confirmed the documentation reflected two smoking incidents involving Patient 3 had occurred, one on 06/17/2023 and one on 06/18/2023. The RM stated there was no incident report generated and no investigation regarding the smoking incident on 06/17/2023.

4.e. Review of the hospital's incident reporting log from 04/01/2023 through 06/28/2023 confirmed no incident report was generated regarding the smoking incident on 06/17/2023 involving Patient 3 reflected in findings 4.c. and 4.d.

5.a. Another medical record regarding Patient 3 was reviewed and reflected that Patient 3 returned to the hospital's ED on 06/19/2023.

* RN documentation dated 06/19/2023 at 0745 reflected "Pt to room 4 via electric w/c ... [states they] left MMC last night AMA ... returns today as [they] realized [they] cannot take care of self and was due today for a surgical consult for LLE amputation ... RA [SpO2] at 84%. Placed on 4L NC ..."

* RN documentation on a "Mandatory Health Screen" dated 06/19/2023 at 1011 reflected "Smoking status/Current Every Day Smoker ... 1/2 PPD ..."

The patient was admitted to the Surg/Peds Unit on 06/19/2023 at 1228.

* Physician notes dated 06/19/2023 at 1543 reflected
- "... persistent left heel pain and shortness of breath ... Patient states [they] left because [they were] not being allowed to smoke inside and [their] wheelchair was taken away as nurses were concerned that [they] would smoke with [their] oxygen on. Since leaving ... has had recurrent left heel pain, worsening shortness of breath ... does not normally wear oxygen at baseline prior to recent hospitalization ..."
- "Review of external records ... Patient was caught smoking with [sic] wearing [their] oxygen while in the hospital, was advised that [they] cannot do this ... admitted to the hospitalist service for further management with surgical consultations pending."

* Physician notes dated 06/20/2023 at 1305 reflected "... patient smokes a pack of cigarettes a day ... Tobacco addiction. Counseled not to smoke, on nicotine patch ..."

Physician notes dated 06/21/2023 at 1200 reflected "...Tobacco addiction. Counseled not to smoke, on nicotine patch ... Requiring supplemental oxygen ..."

* RN documentation dated 06/21/2023 at 1642 reflected the patient had a LLE amputation and was receiving oxygen "2L NC."

* RN documentation dated 06/23/2023 at 0516 reflected "... Patient placed on high flow NC, at 7L O2 by RT. [SpO2] remains 89-90% ..."

* RN documentation dated 06/23/2023 at 1240 reflected "Patient adamant about wanting to leave the hospital. Continually states 'Take me outside', 'I want to smoke', 'Get me my power chair', 'I need my power chair', I'm going to leave'. This RN discussed the risks of going out to smoke, the use/requirements of oxygen and oxygen needs at this time. Continually adamant about wanting [their] chair. This RN notified [physician] of this, stated [physician] should come speak with patient and adjust nicotine orders." Although the patient was adamant about wanting their w/c so they could go outside to smoke, and had repeated episodes of non-compliance with the hospital's Tobacco Free Campus policy including smoking in their room, there was no documentation that reflected the RN asked the patient if they had smoking supplies, checked the patient's room for smoking supplies, assessed the patient's risk for smoking non-complian

Based on observation, interview, review of incident and medical record documentation for 1 of 1 patient who smoked while receiving oxygen therapy in the hospital (Patient 3), review of education/training records for 18 of 18 employees (Employees 1-18), review of education/training records for 2 of 2 medical staff (Staff 19 and 20), review of hospital P&Ps, and review of other documentation it was determined the hospital failed to develop and enforce P&Ps to ensure patients' rights were recognized, protected and promoted and all components of an effective abuse and neglect prevention program were evident, including thorough and complete investigations and follow up actions of potential abuse or neglect, as defined by CMS, to ensure those incidents did not recur.
* The hospital failed to conduct thorough, complete, and timely investigations and follow up actions of at least three smoking and smoking related incidents involving Patient 3 to ensure they did not recur. Thereafter, the patient experienced second and third degree burns and other injuries after an "explosion" and fire occurred when the patient was smoking in their hospital room while receiving six or seven liters of "high flow" oxygen therapy via nasal cannula.

The CMS Interpretive Guideline for this requirement at CFR 482.13(c)(3) reflects "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

Further, the CMS Interpretive Guideline reflects that components necessary for effective abuse protection include, but are not limited to:
o Prevent. A critical part of this system is that there are adequate staff on duty, especially during the evening, nighttime, weekends and holiday shifts, to take care of the individual needs of all patients.
o Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect.
o Train. The hospital, during its orientation program, and through an ongoing training program, provides all employees with information regarding abuse and neglect, and related reporting requirements, including prevention, intervention, and detection.
o Protect. The hospital must protect patients from abuse during investigation of any allegations of abuse or neglect or harassment.
o Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment.
o Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.
As a result of the implementation of this system, changes to the hospital's policies and procedures should be made accordingly.

Findings include:

1. Refer to the findings identified under Tag A144, CFR 482.13(c)(2) - Standard: Patient Rights: Care in a Safe Setting. Those findings reflect the hospital's failure to conduct clear, complete, thorough and timely investigations and follow up actions to potential abuse or neglect incidents, to ensure similar incidents do not recur.

Based on observation, interview, review of incident and medical record documentation for 1 of 1 patient who smoked while receiving oxygen therapy in the hospital (Patient 3), review of education/training records for 18 of 18 employees (Employees 1-18), review of education/training records for 2 of 2 medical staff (Staff 19 and 20), review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to ensure that the QAPI program was effective to ensure the provision of safe and appropriate care to patients in the hospital.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A-0115 under CFR 482.13 - CoP: Patient's Rights.

2. Refer to the findings cited at Tag A-0700 under CFR 482.41 - CoP: Physical Environment.

3. Refer to the findings cited at Tag A-395 under CFR 482.23(b)(3) - Standard: Staffing and Delivery of Care

4. Refer to the findings cited at Tag A-396 under CFR 482.23(b)(4) - Standard: Staffing and Delivery of Care

Based on observation, interview, review of incident and medical record documentation for 1 of 1 patient who smoked while receiving oxygen therapy in the hospital (Patient 3), review of education/training records for 18 of 18 employees (Employees 1-18), review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to ensure the RN supervised and evaluated patients in a manner that ensured the provision of safe and appropriate care in accordance with hospital P&Ps including:
* The RN failed to effectively supervise and monitor a patient, and the patient was allowed repeated access to cigarettes, lighter, matches and other smoking supplies including when receiving oxygen therapy.
* The RN failed to ensure a patient was oriented and instructed on admission to the hospital's Tobacco Free Campus P&Ps.
* The RN failed to ensure timely physician notification of a patient's non-compliance with the hospital's non-smoking P&Ps.

Findings include:

1. Refer to the findings cited at Tag A-0144 under CFR 482.13(c)(2) - Standard: Care in a Safe Setting.

Based on observation, interview, review of incident and medical record documentation for 1 of 1 patient who smoked while receiving oxygen therapy in the hospital (Patient 3), review of education/training records for 18 of 18 employees (Employees 1-18), review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to ensure the RN developed and kept current a nursing care plan based on assessment of the patient's nursing care needs, including individualized goals and interventions.
* The hospital failed to ensure the RN developed and kept current a nursing care plan for Patient 3 who was a known long time smoker with non-compliant smoking behaviors. The patient was allowed repeated access to cigarettes, lighter, matches and other smoking supplies including when receiving six or seven liters "high flow" oxygen therapy.

Findings include:

1. Refer to the findings cited at Tag A-0144 under CFR 482.13(c)(2) - Standard: Care in a Safe Setting.



44104

Based on observation, interview, review of incident and medical record documentation for 1 of 1 patient who smoked while receiving oxygen therapy in the hospital (Patient 3), review of education/training records for 18 of 18 employees (Employees 1-18), review of education/training records for 2 of 2 medical staff (Staff 19 and 20), review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to ensure the physical environment was constructed, arranged, and maintained to ensure the safety of patients.
* Refer to the attached Life Safety from Fire CMS 2567 SOD Report that reflects:
- The hospital failed to maintain, inspect and test automatic sprinkler and standpipe systems as required.
- The hospital failed to ensure staff followed the emergency preparedness and fire safety plans as required.
- The hospital failed to provide fire drills for all staff as required.
- The hospital failed to ensure smoking materials/ignition sources were removed from patients receiving oxygen/respiratory therapy as required.
* The hospital failed to comply with the Life Safety From Fire requirements as indicated on the attached Life Safety from Fire CMS 2567 SOD Report at Tag K925. The findings described at Tag K925 on the LSC SOD report were determined to represent an IJ situation. Refer also to Tag A-0000 at the beginning of this SOD report for the details of the IJ identification, notification, removal plan approval, and verification of removal.
* Patient 3, who was on six or seven liters "high flow" oxygen administered by nasal cannula, was not prevented from accessing smoking supplies and ignition sources in their room. The patient smoked in their room under these conditions and was harmed when a fire ignited. The fire caused the patient serious burn injuries including third degree burns to face, right ear, right shoulder, and right pectoral area; and second degree burns to left hand. The patient had been non-compliant with the hospital's "Tobacco Free Campus" policy at least three times prior to this event, and the hospital failed to take effective preventive actions to prevent recurrence and ensure a safe physical environment, including those required by hospital policy.

Those conditions resulted in actual harm for Patient 3, and potential harm to other patients. Although the hospital had initiated an investigation in response to the fire event and had identified some practice gaps and pending corrective actions, it had not implemented immediate corrective actions to mitigate the possibility of recurrence for other patients while long-term corrective actions were being determined, planned and implemented.

In addition, the hospital's "Tobacco Free Campus" policy was unclear and not fully developed and implemented; and hospital employees and medical staff had not received training regarding the policy.

Although the IJ situation was verified to be removed during the survey, the findings identified during the survey reflect the hospital's limited capacity to provide safe and adequate care and services and represent a Condition-level deficiency.

Findings include:

1. Refer to the findings under K tags K353, K711, K712, and K925 on the Fire Life Safety CMS 2567 SOD report.

2. Refer to the findings cited at Tag A-709 under CFR 482.41(b) - Standard: Life Safety from fire.

3. Refer to the findings cited at Tag A-144 under CFR 482.13 - CoP: Patient's Rights.

Based on observation, interview, and document review, it was determined that the hospital failed to comply with the Life Safety From Fire requirements as indicated on the attached Fire Life Safety CMS 2567 SOD report.

Findings described at Tag K925 on the LSC SOD report were determined to represent an IJ situation. Refer also to Tag A-0000 at the beginning of this SOD report for the details of the IJ identification, notification, removal plan approval, and verification of removal.

Findings include:

1. Refer to the findings under K tags K353, K711, K712, and K925 on the Fire Life Safety CMS 2567 SOD report.