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The Condition of Participation for Patient Rights has not been met.

Based on clinical record reviews, review of hospital policies, review of hospital documentation, and interviews for one of eleven patients reviewed for patient rights (Patient (P) #1), the hospital failed to ensure care was provided in a safe setting when staff failed to implement the fire plan when there was evidence of a fire, and failed to ensure that a patient receiving oxygen did not receive oxygen at a higher rate than what was prescribed.


Please refer to A144

Based on clinical record reviews, review of hospital policies, review of hospital documentation, and interviews for one of eleven patients reviewed for patient rights (Patient (P) #1), the hospital failed to ensure care was provided in a safe setting when staff failed to follow the fire plan when there was evidence of a fire, and for one of eleven patients reviewed for patient rights (P #1), the hospital failed to ensure that a patient receiving oxygen did not receive oxygen at a higher rate than what was prescribed. The findings include:



a. P #1 was a current smoker, had a history of chronic obstructive pulmonary disease (COPD) and was admitted to the hospital on 10/29/21 with a diagnosis of hypoxic respiratory failure.

Physician orders dated 10/29/21 at 10:35 PM directed Oxygen (O2) 2 liters per minute (LPM) via nasal cannula (N/C) for a maximum rate of 2 LPM to maintain O2 saturation (SpO2) at 92% - adjust liter flow by 1 LPM every 5 minutes to maintain target SpO2 over the next 24 hours.

Nursing flow records dated 10/30/21 identified that P #1's O2 was on 4 LPM via nasal cannula at 10:00 AM and SpO2 was 93%.

Nursing narratives dated 10/30/21 indicated that at 2:00 PM, RN #1 noticed a burning smell. P #1 was observed in the bathroom and admitted to smoking (lighting a cigarette) with the O2 tubing on. The note further identified P #1's face had soot on bilateral eyebrows, nose, chin and right foot, the O2 tubing was burnt, and RN #1 called security and additional staff via phone.

P #1 was subsequently assessed by a physician and identified to have second degree burns to the face and right foot and charring that did not extend past the patient's naris/upper epiglottis. Respiratory decompensation was not noted. P #1 was transferred to the stepdown unit for closer monitoring.

The security report dated 10/30/21 identified security was called to Pavilion E at 2:15 PM, the fire department was contacted at 2:20 PM, arrived at 2:30 PM and deemed no further hazard. The fire alarm system was not activated by hospital staff which led to a delay in the safety assessment by local fire officials.

Photographs taken by hospital staff on 10/30/21 noted an approximate 12-inch burn area on the entryway floor to the bathroom, 4 smaller charred areas on the floor inside the bathroom and burnt O2 tubing hanging from the bathroom sink.

Interview with Security Officer (SO) #1 on 11/1/21 at 9:36 AM identified that SO #2 radioed him to Pavilion E, he smelled a burning smell and probably should have pulled the fire alarm.

Interview with SO #2 on 11/1/21 at 10:25 AM indicated he had a radio call to Pavilion E, saw burnt marks on the floor near the bathroom as well as inside the bathroom, and probably should have pulled the fire alarm.

Interview with RN #1 on 11/1/21 at 1:26 PM noted that she smelled something burning, saw black soot on P #1's face and P #1's right toes were black. RN #1 indicated that the O2 tubing was still in P #1's nares and part of the tubing was on the floor. RN #1 identified that she yelled for Clinical Care Associate Unlicensed (CCAU) #1 to help her, they assisted P #1 back to bed and did not activate the fire alarm because she did not see an active fire or flame.

The Hospital policy entitled Departmental Fire Procedures Pavilion E identified if you discover a fire in your area, rescue by removing anyone in immediate danger while calling out, "fire alarm activation, location, for assistance. Close the door to the fire room.

The Hospital policy entitled Patient Rights and Responsibilities identified our patients and team members are expected to maintain a safe environment.

The Hospital Adverse Event Report dated 10/31/21 identified the Fire Marshall coached and mentored nursing staff in real time to pull the fire alarm with this situation as an immediate action. Subsequently, additional education of the Hospital Fire Procedure Policy was initiated hospital- wide immediately following the event.




b. P #1 was a current smoker, had a history of chronic obstructive pulmonary disease (COPD) and was admitted to the Pavilion E unit on 10/29/21 with a diagnosis of hypoxic respiratory failure.

Physician orders dated 10/29/21 at 10:35 PM directed Oxygen (O2) 2 liters per minute (LPM) via nasal cannula (N/C) for a maximum rate of 2 LPM to maintain O2 saturation (SpO2) at 92%- adjust liter flow by 1 LPM every 5 minutes to maintain target SpO2 over the next 24 hours. Although the order directed that the O2 could be adjusted by 1 LPM, the ordered maximum flow rate of 2 LPM did not allow for increased titration.

Nursing flow records identified that on 10/30/21 at 2:00 PM, P #1's O2 was on 4 liters via nasal cannula (2 liters higher than the order allowed) when P #1 lit a cigarette with the O2 tubing on and sustained second degree burns to the face and right foot and charring that did not extend past the patient's naris/upper epiglottis.

Interview with the Director of Quality on 11/9/21 at 11:18 AM noted the oxygen order was unclear.

The Hospital policy entitled Oxygen Management identified nursing or respiratory staff responsibilities included to verify oxygen orders and titrate oxygen per orders.

The Condition of Participation of Physical Environment has not been met.

Based on a review of hospital policies, review of hospital documentation, and interviews, for one patient who was smoking in his/her room while receving oxygen therapy resulting in a fire, the hospital failed to follow the written fire control plans that contain provisions for prompt reporting of fires; extinguishing fires; protection of patients, personnel, and guests; evacuation; and cooperation with firefighting authorities. Refer to A 714

The hospital was not in compliance with the facilities water management plan for legionella bacteria sampling. Refer to A 701

Based on review of hospital documentation, policies, and interviews, the hospital was not in compliance with the facilities water management plan for legionella bacteria sampling. The finding includes:


a. During documentation review it was identified that the hospital was not in compliance with the facilities water management plan developed along with a contracted provider and updated in July 2021 for legionella bacteria sampling and management plan for potable water. It was identified that the facility sampling plan as of July 2019 was to sample 5 % of the total ice machines from different areas in Pavilion A, B, C, D & E and to sample 5 % of the total patient rooms faucets and showers will vary on exact locations to ensures the capture the full length of feed and return of the piping as a way of documentation that the facilities control measures are working. Documentation identified the facility had only tested the lobby water feature, cooling tower, and exterior water fountain.

Subsequent interview with the Regional Facilities Compliance Program Manager and Central Region Facilities Management team identified that this testing interval had been suspended and not updated.

Based on a review of the clinical record, review of hospital policies, review of hospital documentation, and interviews, the Hospital failed to follow the hospital's written fire control plans that contain provisions for prompt reporting of fires; extinguishing fires; protection of patients, personnel, and guests; evacuation; and cooperation with firefighting authorities. The findings include:

a. Review of Patient #1's clinical record (nursing note) dated 10/30/21 indicated that at 2:00 PM, RN #1 noticed a burning smell. Patient #1 was observed in the bathroom and admitted to smoking (lighting a cigarette) with the oxygen (O2) tubing on. The note further identified Patient #1's face had soot on bilateral eyebrows, nose, chin and right foot, the O2 tubing was burnt.

During documentation review on 11/01/2021 at approximately 9:45 AM and review of the hospital policy entitled, Departmental Fire Procedures Pavilion E, the plan stated if you discover a fire in your area, rescue by removing anyone in immediate danger while calling out, "fire alarm activation, location, for assistance, and close the door to the fire room. Interview with RN#1 on 11/21/2021 at 1:26 PM stated she smelled something burning, saw black soot on P #1's face and P #1's right toes were black. RN #1 indicated that the O2 tubing was still in P #1's nares and part of the tubing was on the floor. RN #1 identified that she yelled for Clinical Care Associate Unlicensed (CCAU) #1 to help her, they assisted P #1 back to bed and did not activate the fire alarm because she did not see an active fire or flame. The Charge nurse was subsequently called along with the nursing coordinator who notified security who notified the Meriden Fire Department, and two (2) security officers were sent to the site of the incident.
b. Photographs taken by Hospital staff on 10/30/21 noted an approximate 12-inch burn area on the entryway floor to the bathroom, 4 smaller charred areas on the floor inside the bathroom and burnt O2 tubing hanging from the bathroom sink.
c. The security report dated 10/30/21 identified that the incident occurred at 2:10 PM and that security was called to Pavilion E at 2:15 PM, a delayed notification of five (5) minutes. The report identified that the Meriden fire department was contacted by phone at 2:20 PM, an additional five (5) minute delay in notification to firefighting authorities, the Meriden Fire Department arrived at 2:30 PM and requested the Fire Marshal for a fire investigation and deemed no further hazard. The hospital could reoccupy East Pavilion Room 11 once cleaned. The fire alarm system was not activated by hospital staff which led to a delay in the arrival of the fire department and the fire department stated according to this report that if this were to happen in the future that staff were to activate the fire alarm.
d. Interview with Security Officer (SO) #1 on 11/1/21 at 9:36 AM identified that SO #2 radioed him to Pavilion E, he smelled a burning smell and probably should have pulled the fire alarm.
e. Interview with SO #2 on 11/1/21 at 10:25 AM indicated he had a radio call to Pavilion E, saw burnt marks on the floor near the bathroom as well as inside the bathroom, and probably should have pulled the fire alarm.

f. The Hospital Adverse Event Report dated 10/31/21 identified the Fire Marshall coached and mentored nursing staff in real time to pull the fire alarm with this situation as an immediate action. Subsequently, additional education of the Hospital Fire Procedure Policy was initiated hospital- wide immediately following the event.