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Based on interview, document review, and review of security video footage, the hospital failed to protect the rights of P1 and other patients on the unit and provide care in a safe setting when P1 started a fire, with an unknown ignition source, in the linen closet on Unit Orange 8 at 4:00 p.m on 6/22/17 in 1 of 11 patients reviewed. The fire was contained, the sprinkler system was activated, and the fire was extinguished. The hospital was found not in substantial compliance with the Condition of Participation of Patient Rights at 42 CFR 482.13.

Findings include:

The hospital failed to develop an effective system for protecting the rights of all patients (refer to A144) by closely monitoring contraband that visitors bring into the hospital's locked unit. This failure places the Condition of Participation of Patient Rights out of compliance.

Based on document review, interview and review of security video footage, the hospital failed to protect the rights of P1 and other patients on the unit by having an effective system of monitoring and preventing contraband from being brought into the locked unit by visitors. As a result, P1 used an unknown ignition source to start a fire in the linen closet and caused the sprinkler system and alarm to be activated in 1 of 11 patients reviewed.

Findings include:

P1's hospital record was reviewed and indicated P1 was admitted on 6/13/17 to the hospital's psychiatric Intensive Care Unit (ICU) on the Orange 8 locked inpatient psychiatric unit. The record indicated P1's diagnosis was adjustment disorder with mixed disturbance of emotions and conduct, and P1 had a history of starting a fire. P1 was searched for contraband upon admission to the ICU and his room was searched daily for contraband. P1 was monitored for self injurious behavior on a continuous basis while on the ICU. However, P1 was changed to physician ordered every 15 minute checks when his condition improved on the ICU and prior to his 6/21/17 transfer to the locked psychiatric General Unit.

A Belongings/Valuable flowsheet dated 6/13/17 indicated P1 was searched and his valuables were recorded when he was admitted to the ICU. The flowsheet did not indicate that P1 had a cigarette lighter or matches in his possession on 6/13/17.

A 6/21/17 at 19:58 p.m. progress note indicated P1 was transferred from Orange 8 ICU to Orange 8 General unit due to improved behavior. P1 was to be checked every fifteen minutes on the General Unit.

A 6/22/17 hospital security report, written by Security Officer Supervisor (SOS)-G, indicated a fire was discovered on 6/22/17 at 4:03 p.m. inside a linen closet on the Orange 8 inpatient psychiatric unit. The report indicated arson is suspected and that P1 is the suspect. All patients were immediately moved off of the unit and transferred to other psychiatric units within the hospital. The fire department arrived at 4:13 p.m. The sprinkler system in the area of the fire immediately extinguished the fire, but the water continued to flow until 4:38 p.m. and flooded the entire unit. The report contained video footage that identified P1 entering the linen closet for a short period of time and then walking away with a piece of linen. After several minutes patients in the area began to notice smoke and water coming from the linen closet, and the fire alarms began to alarm. The video revealed that no one else had entered the linen closet after the time that P1 entered the closet. The report stated the fire burned linen, shelving and the sheet rock on the wall. It was determined that P1 had several medical conditions, in addition to mental problems, and that charges would be filed against P1, but P1 would not be taken to jail. No injuries occurred as a result of the fire.

A Hennepin County Sheriff's Office Incident Report, dated 6/22/17, described the fire, all of the evidence, and indicated P1 denied being responsible for starting the fire. The report indicated that per Arson Investigation findings, the cause and source of the fire was the introduction of an open flame. The report indicated that the hospital determined that the cost of repair of damages related to the fire, smoke and extensive water damage will be excessive.

Hospital incident reports, dated 6/22/17 and 6/23/17, indicated the Orange 8 Unit was closed immediately following the fire, but the ICU Unit was expected to open on 6/24/17 at 4:00 p.m. following repairs.

The State Fire Marshal Division's report related to the 6/22/17 fire stated the fire in the linen closet was determined to be arson. The Minneapolis Fire Department arrived at the hospital at 4:13 p.m. on 6/22/17 and verified that the sprinkler system had extinguished the fire. The report indicated fire, smoke and significant water damage from the sprinkler system was evident. The report contained the following recommendations/suggestions for follow up action: 1) All patients in psychiatric units should be thoroughly searched for sources of ignition. 2) Visitors should be informed of the rules related to bringing contraband into the psychiatric units.

The Orange 8 Unit (General and ICU) were toured on 6/23/17 at 2:30 p.m. and on 6/26/17 at 9:30 a.m. It was noted that repairs were in progress on 6/23/17 and no patients were present on the two units. Repairs had been completed on the ICU when the investigator toured on 6/26/17 (8 patients were in ICU), but the repairs on the General Unit were still in progress and expected to continue for 2-3 weeks and no patients were present on the General Unit. It was noted that there were nine lockers at the entrance to the General Unit and there were notes on them that requested visitors to place belonging in the lockers before entering the unit.

Administrative RN-(A) was interviewed in person on 6/23/17 3:00 p.m., and she stated some immediate changes are planned and will be implemented in response to the fire and prior to patients returning to the units. The changes are: 1) Increase monitoring of visitors and what they bring into the unit. 2) Search patient rooms in ICU on each shift and once a day on General Unit. 3) Require visitors to use lockers prior to entering the unit 4) Assign a mental health worker to be present at the front door and escort visitors onto the unit. 5) Place a more visible sign (containing locker use guidelines) at the entrance to the unit.

The hospital's Family and Visitor Property (Psychiatry) policy, dated July 2007 and revised October 2014, indicated the purpose of the policy was to provide a safe and therapeutic environment and reduce the risk for contraband/unapproved items from entering the unit. The policy described a procedure for family and visitors to place their belonging in a secured area before they interact with patients and identified the contraband items that needed to be secured before entry to the unit.

A supply of papers titled Guidelines for Inpatient Psychiatry, dated 8/10/15, are available at the entrance to the Orange 8 Unit (General and ICU) for visitors to take and review. However, review of the paper was not a mandatory requirement prior to entering the unit. The paper (guideline) provided information to visitors pertaining to visiting hours and contraband items that are not allowed on the unit, including lighters and matches.