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Based on medical record review and staff interviews, the Emergency Mental Health (EMH) staff failed to ensure the safety of one of one applicable Patients [Patient #1] and other patients and staff because a personal safety check/search had not been conducted at the time of arrival to the Emergency Department's Emergency Mental Health (EMH) Unit on 12/28/11.

Findings include.

1. Review of the Emergency Department EMH Unit medical record indicated that the local police escorted Patient #1 to the ED in handcuffs after destructive behaviors were observed in the basement of a crisis stabilization/mental health facility within the community. The University Police accompanied Patient #1 into the EMH Unit to assist with the admission process.

2. Review of the EMH Adult Comprehensive Assessment dated 12/28/11 indicated that a Mental Health Clinician conducted a personal safety assessment during the admission process. However, the safety check document section included a crossed out entry for the name of the person who conducted the search and entered the name of another mental health associate, hours after the arrival of Patient #1 to the ED EMH Unit.

3. The EMH Nurse Manager was interviewed in person on 01/30/12 at 3:30 P.M. and again on 01/31/12 at 3:30 P.M. The EMH Nurse Manager said that the mental health associates were responsible for conducting personal safety searches at the time of the patients arrival.

4. Registered Nurse #1 was interviewed in person on 01/30/12 at 5:30 P.M. RN #1 said that Patient #1 did not answer the safety questions and refused to cooperate during the admission process. RN #1 relied on the information provided by the local police that Patient #1 had been searched and contraband items were removed .

5. Review of the Emergency Mental Health Attending/LIP Evaluation dated 12/28/11 (time unknown) indicated that Patient #1 had a history of arson and numerous psychiatric hospitalizations.

6. On 12/28/11, approximately fifteen hours after admission to the EMH Unit, Patient #1 ignited the bed linens with a cigarette lighter and caused a fire.

7. Mental Health Counselor (MHC) #1 was interviewed in person on 01/30/12 from 6:13 P.M. to 6:40 P.M. and RN # 2 was interviewed by telephone on 01/31/12 from 12:15 P.M. to 12:50 P.M. Both said that Patient #1 could easily become explosive and destructive to property. Both denied having any knowledge that Patient #1 had a history of arson.

8. The Hospital failed to ensure that Patient #1, other patients and staff were protected from the threat of serious injury and harm by fire and smoke. The Hospital failed to ensure that personal safety searches were conducted in a timely manner for patients evaluated in the EMH unit.

9. Patient #1 was not thoroughly checked for contraband and on 12/28/11 at 7 P.M. Patient #1 ignited the bed linens with a cigarette lighter causing a fire.

Refer to A-0267 and A-0467

Based on medical record review and staff interviews, the Hospital did not identify and ensure patient safety in the Emergency Department, Emergency Mental Health (EMH) Unit following a serious reportable event of a fire in a locked unit on 12/28/11.

Findings include:

1. Patient #1 set fire to the bed to Room #5 on 12/28/11 at 7 P.M.

2. The Hospital's action plan dated 01/17/12 indicated that after the fire in the EMH Unit, the interview rooms located in the EMH Unit would no longer be accessible to patients without direct supervision.

Based on interviews and medical record reviews, four of ten Emergency Mental Health (EMH) Records lacked appropriate documentation that a personal safety search had been conducted for patients identified as at risk for personal safety.

Findings included:

1. Review of the EMH Adult Comprehensive Assessment dated 12/28/11 for Patient #1 indicated that Mental Health Clinician #2 documented that a personal safety check had been conducted by a mental health associated, then crossed out the name of the mental health associate and entered a second name of a mental health associate onto the record.

a. Mental Health Clinician (MHC) #2 was interviewed by telephone on 02/02/12 at 11 A.M. MHC #2 said that he evaluated Patient #1 on 12/28/11 between 10 A.M. to 12 P.M. Patient #1 arrived to EMH at approximately 5 A.M. on 12/28/11. It was not clear as to how MHC #2 confirmed that the search was done for Patient #1 when the mental health associate was not working on the unit at the time MHC #2 conducted Patient #1's Adult Comprehensive Assessment.

b. The EMH Nurse Manager said the mental health associates were responsible for the personal safety searches. However, the mental health clinicians documented in the Adult Comprehensive Assessments that the searches are done without clear verification that the searches had been completed. Patient #1 did not have a personal safety search by the EMH staff.

2. Review of Patient # 4's EMH Adult Comprehensive Assessment dated 12/05/11 lacked documentation that a personal safety search was conducted. Patient #4 was being evaluated for suicidal ideation..

3. Review of Patient #7's EMH Adult Comprehensive Assessment dated 09/07/11 lacked documentation that a personal safety search was conducted. Patient #7 was being evaluated for suicidal ideation.

4. Review of Patient #10's EMH Adult Comprehensive Assessment dated 09/12/11 indicated that the personal safety search had been conducted in the ED on the North Pod side. Review of the ED Record for Patient # 10 lacked documentation that a personal safety search had been conducted.

5. There were inconsistencies in the documentation on the EMH Adult Comprehensive Assessments that personal safety searches were conducted and verified at the time of the patients arrival into the EMH Unit.