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A. Based on a review of Hospital policy and procedure, internal documents, medical record review and staff interview, it was determined that the Hospital failed to follow safe standards of practice in order to ensure patient safety in the surgical area. As a result, the Condition of Patient Rights was not met.
The cumulative effect of the failure to follow standards of practice resulted in a surgical fire in 1 of 1 (Pt. #1)causing an inpatient 1st degree burns, intubation, respiratory airway burn and subsequent transfer to another facility for specialized care.
Findings include:
The Hospital failed to ensure that safe standards of practice were followed in 1 of 1 patient records (Pt. #1) by all staff in assessing the environment for potential fire hazards while providing care for patients undergoing surgical procedures. See deficiency cited at A-0144.

A. Based on a review of Hospital policy and procedures, record review and staff interview, it was determined that the Hospital failed to follow standards of practice in assessing and caring for 1 of 1 (Pt #1) to prevent harm from a surgical fire.
Findings include:
1. The medical record of Pt. #1 was reviewed on 8/3/11. Pt. #1 was admitted to the Hospital on 7/22/11 with diagnoses of Acute Cellulitis left leg, Hypertension, Gastric Reflux, Degenerative Joint Disease and Anxiety. Documentation indicated a past medical history of Chronic Obstructive Pulmonary Disease and use of oxygen by Pt. #1 at 3L per nasal cannula. Documentation indicated the History & Physical dictated 7/23/11 under Plan indicated a consultation for a Port A Cath placement because of " recurrent need for IV therapy. " Documentation indicated Pt. #1 was taken to surgery at 0815 on 7/25/11 for placement of the port. Documentation on the anesthesia record indicated Pt. #1 was placed on 10L of oxygen per mask with O2 saturation at 98-100% during the procedure. During an interview with the Certified Registered Nurse Anesthetist (CRNA) on 8/3/11 at 12:30 PM, it was reported that Pt. #1 requested to be asleep during the procedure and was given additional sedation during the procedure. The CRNA reported due to Pt. #1 ' s history of COPD and being given the additional sedation she felt Pt. #1 needed the oxygen at the higher rate of 10L. During the interview the CRNA also reported Pt. #1 had a " thick neck " causing limited space for air movement. During an interview with the OR Manager on 8/3/11 at 12:45 PM, it was demonstrated that a surgical towel was placed on each side of Pt. #1 ' s neck for stabilization. The CRNA reported she constantly assesses drapes over the head to ensure air flow and venting of gasses. Documentation in the operative notes indicated the procedure started at 0832 and at 0906 sparks were noted at the incision site from the bovie tip being used to cauterize small bleeders. Documentation indicated " flames engulfed drapes and spread to face, neck and left chest. Fire extinguished per water. Intubation to follow (0910) without difficulty. Blackened mask. Tubes and sponges removed from patient. Procedure finished as planned. The fuel of the guidewire and the oxidizer of the oxygen at 10L, with the the position of the drape did not adequately vent the gases and was ignited by the bovie/spark. Pt transferred to ICU per staff .... Skin peeled back on chest, neck and face. Hair singed at hairline and left temporal area. Soot noted around nares. " Documentation indicated Pt. #1 remained in the ICU (intensive Care Unit) and an attempt to extubate her was performed on 7/27/11 and was unsuccessful. Documentation indicated Pt. #1 was transferred to a facility with a specialized burn unit on 7/28/11.
2. A review of Hospital policies was completed on 8/3/11. The Hospital policies reviewed included " Surgical Draping " , " Patient Safety in Surgical Services " , Perioperative Safety " and " Fire Plan " . A review of the policies indicated that policies failed to include areas to ensure patient safety from fire including, fire risk assessment, surgical draping to ensure proper gas dissipation, removal of unnecessary linens that could cause gas build up, removal of linens saturated with alcohol based solutions, assessment of use of lowest possible oxygen amount for patients needing oxygen and assessment of use of lowest possible cautery settings.
3. A review of the training material for all patient care staff titled, " Fire Safety in the Operating Room " indicates under risk reduction, " tent drapes to allow gases to dissipate away from the OR table. " There was no documentation to indicate that the drape placed between the surgical field and the patient's head was placed in a manner to prevent gas build up.
4. During an interview with the Chief Medical Officer on 8/3/11 at 5:15 PM, the above findings were confirmed.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Federal Complaint Investigation conducted on August 2, 2011, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Federal Complaint Investigation conducted on August 2, 2011, the surveyor(s) find(s) that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated August 2, 2011.

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A. Based on a review of Hospital policy and procedure, internal documents, medical record review and staff interview, it was determined that the Hospital failed to follow safe standards of practice in order to ensure patient safety in the surgical area. Also, the Hospital failed to ensure that corrective actions were implemented in a timely manner in order to prevent further incidents of fire in the surgical area. As a result, the Condition of Surgical Services was not met.

The cumulative effect of the failure to follow standards of practice resulted in a surgical fire 1 of 1 (Pt. #1)causing an inpatient 1st degree burns, intubation, respiratory airway burn and subsequent transfer to another facility for specialized care. The corrective actions taken by the Hospital did not adequately address the processes in the surgical department that would eliminate the potential for another surgical fire for the monthly average of 225 surgical patients.

An Immediate Jeopardy and serious threat to this patient ' s safety as well as other patients receiving surgical procedures was created from the cumulative effects of this systemic practice.

Findings include:
An Immediate Jeopardy was identified on 08/03/11 at 11:30 AM with the Chief Medical Officer (CMO), Chief Nurse Executive (CNE), Director of Quality and Care Management and the Manager/Operating Room present. The Hospital failed to ensure that safe standards of practice were followed in 1 of 1 patient records (Pt. #1) by all staff in assessing and providing care for this patient undergoing surgical procedures. The Hospital failed to implement corrective actions and did not provide timely education to all surgical staff related to changes in the surgical care of patients whose procedure could be determined to be a potential risk for fire. See deficiency cited at A-0951.
At the time of the exit conference on 08/03/11 at 5:15 PM the Immediate Jeopardy remained in effect.

A. Based on a review of Hospital policy and procedures, internal document review, record review and staff interview, it was determined that the Hospital failed to follow standards of practice in assessing and caring for 1 of 1 (Pt #1) and all surgical patients for surgical fire risk.

Findings include:
1. The medical record of Pt. #1 was reviewed on 8/3/11. Pt. #1 was admitted to the Hospital on 7/22/11 with diagnoses of Acute Cellulitis left leg, Hypertension, Gastric Reflux, Degenerative Joint Disease and Anxiety. Documentation indicated a past medical history of Chronic Obstructive Pulmonary Disease and use of oxygen by Pt. #1 at 3L per nasal cannula. Documentation in the History & Physical dictated 7/23/11 under Plan indicated a consultation for a Port A Cath placement because of " recurrent need for IV therapy. " Documentation indicated Pt. #1 was taken to surgery at 0815 on 7/25/11 for placement of the port. Documentation on the anesthesia record indicated Pt. #1 was placed on 10L of oxygen per mask with O2 saturation at 98-100% during the procedure. During an interview with the Certified Registered Nurse Anesthetist (CRNA) on 8/3/11 at 12:30 PM, it was reported that Pt. #1 requested to be asleep during the procedure and was given additional sedation during the procedure. The CRNA reported due to Pt. #1 ' s history of COPD and being given the additional sedation she felt Pt. #1 needed the oxygen at the higher rate of 10L. During the interview the CRNA also reported Pt. #1 had a " thick neck " causing limited space for air movement. During an interview with the OR Manager on 8/3/11 at 12:45 PM, it was demonstrated that a surgical towel was placed on each side of Pt. #1 ' s neck for stabilization. The CRNA reported she constantly assesses drapes over the head to ensure air flow and venting of gasses. Documentation in the operative notes indicated the procedure started at 0832 and at 0906 sparks were noted at the incision site from the bovie tip being used to cauterize small bleeders. Documentation indicated " flames engulfed drapes and spread to face, neck and left chest. Fire extinguished per water. Intubation to follow (0910) without difficulty. Blackened mask. Tubes and sponges removed from patient. Procedure finished as planned. The fuel of the guidewire and the oxidizer of the oxygen at 10L, with the the position of the drape did not adequately vent the gases and was ignited by the bovie/spark. Pt transferred to ICU per staff .... Skin peeled back on chest, neck and face. Hair singed at hairline and left temporal area. Soot noted around nares. " Documentation indicated Pt. #1 remained in the ICU (intensive Care Unit) and an attempt to extubate her was performed on 7/27/11 and was unsuccessful. Documentation indicated Pt. #1 was transferred to a facility with a specialized burn unit on 7/28/11.

2. A review of Hospital policies was completed on 8/3/11. The Hospital policies reviewed included " Surgical Draping " , " Patient Safety in Surgical Services " , Perioperative Safety " and " Fire Plan " . A review of the policies indicated that policies failed to include areas to ensure patient safety from fire including, fire risk assessment, surgical draping to ensure proper gas dissipation, removal of unnecessary linens that could cause gas build up, removal of linens saturated with alcohol based solutions, assessment of use of lowest possible oxygen amount for patients needing oxygen and assessment of use of lowest possible cautery settings.
3. A review of the training material for all patient care staff titled, " Fire Safety in the Operating Room " indicates under risk reduction, " tent drapes to allow gases to dissipate away from the OR table. " There was no documentation to indicate that the drape placed between the surgical field and the patient's head was placed in a manner to prevent gas build up.
4. During an interview with the Chief Medical Officer on 8/3/11 at 5:15 PM, the above findings were confirmed.

B. Based on internal document review, record review and staff interview it was determined that the Hospital failed to ensure that corrective action was taken in a timely manner in order to prevent future surgical fires.
Findings include:
1. During the initial conference with the CNE, CMO and the Director of Quality, on 8/3/11 at 10:00 AM, a request was made for documentation of the corrective actions implemented since the time of the incident on 7/25/11. The CNE presented 2 documents per this request. One document labeled " OR FIRE " indicated an action plan with 5 points for " medical staff sharing. " It was reported by the CNE that the information had been discussed with physicians but no documentation of education or implementation was produced. The second document titled " Fire Prevention in the Perioperative Practice Setting " was presented with a note attached " to be shared with medical staff. " There was no documentation to indicate that the information was shared with any staff. A third document was presented by the Director of Anesthesia. This was documentation of a meeting held 8/2/11 with the anesthesia department. The minutes included a statement under " new business " " Fire in the OR- .... A power point presentation regarding " Fire in the OR ' . All providers will be required to attend. " A second request was made at approximately 11:15 for documentation to indicate staff training, policy changes or an analysis of the incident. Documents were presented at approximately 1:00 PM including a general summary of " morning huddles " that discussed plans for changes to patient assessment and plans to present a power point program related to fire risk. During an interview with the CNE, it was reported that the plans discussed have not been implemented. Also, the CMO presented a document dated 8/3/11 which reported the " policies on fire avoidance and management in the OR " were reviewed " immediately after the incident. " No documentation of changes in policies was presented during the survey. A third request was made for evidence of action related to the incident at 3:15 PM. At this time the Root Cause Analysis was presented which included 9 actions to be taken. The actions include, 1. OR staff to always ensure the prep is dry before beginning procedure, 2. The use of blue sticky drapes will now be used. 3. OR staff to ensure drapes are always taut, 4. The use of IO Band will be instituted, 5. The OR staff will have a fire risk assessment added to their time out, 6. The fire extinguisher will be moved from the back corner to the right area as you walk in the door of OR one. (the extinguisher was not needed for the fire however, the OR team felt it should be more accessible.), 7. The current intercom system does not work or the entire OR area. This needs to be fixed., 8. The use of the bovie needs to be set at the lowest possible setting when possible., 9. The physician needs to announce when he is beginning the use of the cautery during head and neck cases. During a tour of the surgical suite #1 on 8/3/11 at 12:00, it was observed that #6 of the action plan from the RCA to move the fire extinguisher had been completed. During an interview with the OR Manager at the time of the tour, it was reported that the use of blue sticky drapes has been implemented 7/26/11 (#2 on the action plan). Also, a new hospital form titled " Surgical Fire Risk Assessment/Documentation " was presented as well as a sign in sheet indicating staff training on the form was completed on 8/3/11 at 1340. Only 2 of the 9 actions had been implemented as of 8/3/11 at 5:15 PM.
2. A review of patient records was completed on 8/3/11. Documentation indicated that in 6 of 6 records reviewed of surgical patients with similar surgical procedures that were performed after 7/25/11, there was no documented fire risk assessment.
3. During the exit interview with the CMO, CNE, Director of Quality, OR Manager, and Human Resource Manager at 5:15 PM, the above findings were confirmed.