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Based on interview, documentation review, and observation, the facility failed failed to ensure a system was in place to ensure all patients are educated on the prohibition of electronic cigarettes in order to provide a safe physical environment (A701). The facility's census is 155 patients.

Based on observation, interview, policy review, and medical record review, the facility failed to take steps to ensure all patients are educated on the prohibition of electronic cigarettes on hospital property. The facility's census is 155 patients.
Findings include:
1. Interview with Staff A completed on 01/09/17 at 11:00 AM revealed a fire happened on 01/06/17 at 10:35 PM. Patient #1 (Pt. #1) was on oxygen and used an electronic cigarette, the electronic cigarette caused the patient's oxygen to ignite which caused the patient's facial hair and bed linens to catch fire. Pt #1 pulled the oxygen apparatus off his/her face and the nursing staff used blankets to put the fire out. Staff A stated that the patient had no respiratory issues related to the fire but did sustain 2nd degree burns to the face, chest, and hands. Staff A also stated that the sprinklers activated appropriately and the fire department came in and finished putting the fire out.

2. Tour of the patient care unit where the fire occurred completed on 01/09/17 revealed in room 617 a scorched area in the flooring. The room was noted to have been cleared of all furniture and no other damage was noted on the walls or ceiling tiles. Staff stated the tiles were cleaned and replaced due to smoke and water damage.

3. Review of the photographs of the room after the fire completed on 01/10/17 revealed sections of the bed, table, and patient items were burnt and melted.

4. Review of the medical record for Pt. #1 completed on 01/10/17 revealed an admission date of 12/25/16 with a primary diagnosis of acute chronic heart failure and exacerbation of chronic obstruction pulmonary disease. Documentation revealed the patient's social history was assessed on 12/26/16 with Pt. #1 denying the use of tobacco, again on 12/28/16 denying ever using tobacco products, and lastly on 01/07/17, after the fire occurred on 01/06/17, the assessment was changed to current every day smoker and stated vaper use. None of the previous documentation showed the patient was assessed for using vaper/electronic cigarettes. This finding was verified by Staff A at the time of the documentation review.

5. Review of no smoking signage in the facility completed on 01/09/17 revealed electronic cigarettes were not noted as prohibited on the signs seen.

6. Review of the manual given to patients upon admission completed on 01/09/17 revealed a section stating " Smoking- In consideration of patients, visitors and staff, we are a smoke-free campus. You can request a nicotine replacement alternative from your physician " . No reference to the use of electronic cigarettes was noted in the manual.

7. Review of the Debriefing documentation completed on 01/09/17 revealed the Incident happened was reported at approx. 10:45 PM of fire involving patient using an e-cig while on Oxygen. Fire department on scene, fire contained and extinguished, patient was taken to ED for treatment of 2nd degree burns to face. The AOC arrived to hospital at approximately 11:02 PM and assisted supervisor and staff in evacuating the 33 patients from the floor to other areas of the hospital. 6 staff members taken to Emergency Department for evaluation and or treatment of smoke related issues. At 11:12 PM initiated a code yellow requesting all leadership to come and set up incident command. All patients evacuated by approximately 11:40 PM and incident command set up at approximately 11:50 PM.