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Based on policy review, review of medical records, and staff interview, the facility failed to ensure staff followed the facility's policy in reporting all patient safety events for one of ten medical records reviewed (Patient #1). The had the potential to affect all 766 patients receiving services from this facility.

Findings include:

Review of the "Patient Safety Event Reporting" policy revealed staff were responsible to report in a timely manner all patient safety events. A patient safety event was defined as an event, incident, or condition that could have resulted or did result in harm to a patient or any happening that was not consistent with routine operations or routine care. Staff who witnessed, discovered, received or were involved with an event were required to report the event via the online reporting system by the end of the shift on which the event occurred.

Review of the medical record for Patient #1 revealed the patient was admitted on 06/07/17 for shortness of breath, pneumonia and right pleural effusion. The respiratory therapy note dated 06/07/17 at 8:31 PM documented the patient was a current everyday smoker who smoked 0.25 packs per day of cigars. The patient was on two liters of oxygen per nasal cannula. The nurse's note dated 06/12/17 at 8:52 PM documented the patient went off the unit with family at 8:01 PM on four liters of oxygen per nasal cannula. At 8:35 PM, the family brought the patient back to the unit because the cigarette the patient lit had ignited the oxygen. The patient had missing skin to the right cheek and upper lip. The physician was paged. The physician's note on 06/12/17 at 9:07 PM stated the patient had singed nasal hairs and black soot in the right nares, a partial thickness burn just above the upper lip, and a three centimeter by three centimeter burn to the right cheek. The patient had no signs of airway injury or respiratory complaints. A burn consult was ordered. The note from the burn consult on 06/12/17 at 9:12 PM noted superficial burns to the right cheek and upper lip, and singed nares hairs and moustache. The physician ordered ointment to the burns twice a day.

On 06/19/17 at 3:15 PM, Staff A stated that they were unable to find any report in the reporting system regarding the "flash burn" to Patient #1 the previous week. The facility was looking into why this was not entered into the reporting system per their policy.

On 06/20/17 at 9:48 AM, Staff G stated that he/she had begun looking into why this event was not entered into the system when it came to his/her attention. So far the staff had stated to Staff G that since this incident was not witnessed but just reported to them, they were not aware this had to be entered into the reporting system. Staff G stated they had identified a need for further education on what needed entered into the reporting system. Staff G stated the medical record for Patient #1 did contain documentation that the patient was examined right away and appropriate medical care was provided even though it was not recorded in the reporting system.

Based on review of medical records and staff interview, the facility failed to ensure nurses provided care, including education to patients regarding safety precautions, to prevent injury (A395). The cumulative effect of these systemic practices resulted in the facility's inability to ensure safe care for all patients.

Based on review of medical records and staff interview, the facility failed to ensure nurses provided care, including education to patients regarding safety precautions, to prevent injury for one of ten medical records reviewed (Patient #1). This had the potential to affect all 766 patients receiving services from this facility.

Findings include:

Review of the medical record for Patient #1 revealed the patient was admitted on 06/07/17 for shortness of breath, pneumonia and right pleural effusion. The respiratory therapy note dated 06/07/17 at 8:31 PM documented the patient was a current everyday smoker who smoked 0.25 packs per day of cigars. The patient was on two liters of oxygen per nasal cannula. The patient education section of the electronic record contained documentation the patient was educated on 06/09/17 regarding oxygen therapy, avoiding tobacco use/exposure and medical equipment and supplies. The education record lacked documentation as to the specific information the patient was given on these topics.

The nurse's note dated 06/12/17 at 8:52 PM documented the patient went off the unit with family at 8:01 PM on four liters of oxygen per nasal cannula. At 8:35 PM, the family brought the patient back to the unit because the cigarette the patient lit had ignited the oxygen. The patient had missing skin to the right cheek and upper lip. The physician was paged. The patient stated he/she "wasn't thinking".

The physician's note on 06/12/17 at 9:07 PM stated the patient had singed nasal hairs and black soot in the right nares, a partial thickness burn just above the upper lip, and a three centimeter by three centimeter burn to the right cheek. The patient had no signs of airway injury or respiratory complaints. A burn consult was ordered.

The note from the burn consult on 06/12/17 at 9:12 PM noted superficial burns to the right cheek and upper lip, and singed nares hairs and moustache. The physician ordered ointment to the burns twice a day. The patient was advised against smoking while using oxygen.

The discharge instructions included instructions regarding not smoking while on oxygen and oxygen precautions.

On 06/20/17 at 9:48 AM, Staff F and G were interviewed. Staff G stated he/she had interviewed the Assistant Nurse Manager on night shift when this happened and was told that the patient had requested to go outside with family for some fresh air. Staff G stated the patient had not mentioned wanting to smoke to anyone and the patient stated he/she knew they were not supposed to smoke when wearing oxygen, but did not think it would happen. Staff G stated the staff had reported the patient had taken the nasal cannula out of his/her nose and had it hanging around the neck, but had not turned the oxygen off. Staff F and G stated the education documentation did not specify the material covered just the topic itself. Staff G stated that if the patient had mentioned wanting to smoke they would have educated him/her on the dangers of smoking while on oxygen and the appropriate steps to take if he/she still insisted on smoking.

Staff H and N were interviewed by phone on 06/20/17 at 12:52 PM and 3:46 PM respectively. Staff H and Staff N had taken care of Patient #1 prior to the burns. Both stated they had not educated the patient on oxygen safety or not smoking while on oxygen.

On 06/20/17 at 2:47 PM, Staff E verified that they were unable to find any documentation as to what "oxygen therapy" education meant. Staff E stated that based on Patient #1's comments after the incident, he/she was aware of the risk of smoking while on oxygen but agreed that did not reveal where he/she obtained that knowledge. Staff E stated that the only clear indicator that education was provided to the patient on oxygen safety and not smoking while on oxygen was after the patient had been burned. Staff E stated the facility policies regarding oxygen use and safety did not speak to education of patients. Staff E stated that the education documentation would be the same for all patients, unless additional comments were entered in a staff note as the education section for the electronic record was the same.

This substantiates Substantial Allegation OH00091839.

Based on review of medical records, and staff interview; the facility failed to ensure respiratory therapists provided care, including education to patients regarding safety precautions, to prevent injury (A1152). The cumulative effect of these systemic practices resulted in the facility's inability to ensure safe care for all patients.

Based on review of medical records and staff interview, the facility failed to ensure respiratory therapists provided care, including education to patients regarding safety precautions, to prevent injury for one of ten medical records reviewed (Patient #1). This had the potential to affect all 766 patients receiving services from this facility.

Findings include:

Review of the medical record for Patient #1 revealed the patient was admitted on 06/07/17 for shortness of breath, pneumonia and right pleural effusion. The respiratory therapy note dated 06/07/17 at 8:31 PM documented the patient was a current everyday smoker who smoked 0.25 packs per day of cigars. The patient was on two liters of oxygen per nasal cannula. The patient education section of the electronic record contained documentation the patient was educated on 06/09/17 regarding oxygen therapy, avoiding tobacco use/exposure and medical equipment and supplies. The education record lacked documentation as to the specific information the patient was given on these topics.

The nurse's note dated 06/12/17 at 8:52 PM documented the patient went off the unit with family at 8:01 PM on four liters of oxygen per nasal cannula. At 8:35 PM, the family brought the patient back to the unit because the cigarette the patient lit had ignited the oxygen. The patient had missing skin to the right cheek and upper lip. The physician was paged. The patient stated he/she "wasn't thinking".

The physician's note on 06/12/17 at 9:07 PM stated the patient had singed nasal hairs and black soot in the right nares, a partial thickness burn just above the upper lip, and a three centimeter by three centimeter burn to the right cheek. The patient had no signs of airway injury or respiratory complaints. A burn consult was ordered.

The note from the burn consult on 06/12/17 at 9:12 PM noted superficial burns to the right cheek and upper lip, and singed nares hairs and moustache. The physician ordered ointment to the burns twice a day. The patient was advised against smoking while using oxygen.

The discharge instructions included instructions regarding not smoking while on oxygen and oxygen precautions.

On 06/19/17 at 1:00 PM, Staff O was interviewed. Staff O stated that respiratory therapists provided education to the patients regarding everything they were doing. Patients on oxygen would be educated on oxygen use and precautions during routine care. Staff O stated this was not documented, but was part of the routine. Smoking was not allowed anywhere on the hospital campus so smokers were offered alternatives to smoking and a smoking cessation program, including nicotine gum and patches. Staff O stated that most smokers refused.

On 06/20/17 at 2:47 PM, Staff E verified that they were unable to find any documentation as to what "oxygen therapy" education meant. Staff E stated that based on Patient #1's comments after the incident, he/she was aware of the risk of smoking while on oxygen but agreed that did not reveal where he/she obtained that knowledge. Staff E stated that the only clear indicator that education was provided to the patient on oxygen safety and not smoking while on oxygen was after the patient had been burned. Staff E stated the facility policies regarding oxygen use and safety did not speak to education of patients. Staff E stated that the education documentation would be the same for all patients, unless additional comments were entered in a staff note as the education section for the electronic record was the same.

This substantiates Substantial Allegation OH00091839.