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Based on observation, interview, record review, video monitoring, and policy review the nursing staff failed to conduct an internal investigation to determine the exact causation and form a plan of action to prevent the recurrence of a fire, provide a safe environment for 21 of 21 patients on the Behavioral Health Unit (BHU), two north, by allowing one discharged patient (#1) of one reviewed, to have access to contraband (harmful material). Nursing staff also failed to provide direction/education on evacuation of disabled patients. These failures had the potential to lead to injury and death, and could affect all patients in the hospital.

Refer to 2567 (A144)

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient Rights.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 02/22/18, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 02/22/18, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Contraband searchs of the units and all patient rooms began on 02/22/2018 and will continue daily.
- On arrival to the intake unit, an the inpatient unit from any other unit within the hospital, two staff members will supervise the patient removing clothes and change into hospital pajamas.
- Footwear will be removed and the patient will be given non-slip socks.
- Security will scan all patients with metal detecting wand.
- All patient belongings will be secured and placed in a locked locker.
- Belongings brought to patients after admission will be searched and secured by nursing staff.
- After completion of patient search, this will be documented on Patient Referral Log in the Assessment Unit or on the Belongings Checklist in the Inpatient Unit.
- When a patient is searched after identification of contraband, this will be documented on the Unit Contraband Search Log and reviewed by supervisor daily, as well as the Belongings Checklist to ensure compliance.
- All staff will be trained to identify and safely remove contraband.
- If contraband is identified in the patient's room, the patient will be searched and will follow the same process as completed on arrival to inpatient unit.
- Fire and evacuation drills began 02/22/18.
- Drills will be repeated weekly for the subsequent month, then monthly for the following quarter and then quarterly.
- Drills will include safe evacuation of non-ambulatory or disabled patients.
- All clinical staff will complete in person training, starting 02/22/18, on use and location of evacuation equipment.
- Training logs will be monitored to ensure 100% completion of required training during first scheduled patient care shift.

Based on observation, interview, record review, video monitoring, and policy review the nursing staff failed to:
- Conduct an internal investigation to determine the exact causation and form a plan of action to prevent the recurrence of a fire;
- Provide a safe environment for 21 of 21 patients on the Behavioral Health Unit (BHU), two north, by allowing one discharged patient (#1) of one patient reviewed to have access to contraband (harmful material); and
- Provide direction/education on evacuation of non ambulatory patients in emergency situations.
These failures had the potential to lead to injury and death, and could affect all patients in the hospital. The facility census was 450 and the BHU census was 55.

Findings included:

1. Record review of the facility's self-report showed the following:
- A fire occurred on 02/11/18 at 1:30 PM;
- A patient set bedding on fire with a lighter; and
- The unit was evacuated, some staff was treated and released, but no detailed information was available.

During an interview on 02/20/18 at 4:00 PM, Staff A, Patient Safety Performance Coordinator, stated that as of 02/20/18 at 4:15 PM, there were no corrective actions or plan in place to protect the patients and to prevent this incident from happening again. She stated that they were waiting to form a plan after an RCA meeting which was scheduled for 02/23/18, 12 days after the fire occurred.

2. Record review of the facility's "Psychiatric Center Operations Meeting Agenda," dated 02/12/18, showed the following:
- Working to schedule a Root Cause Analysis (RCA) of incident.
- Will need to evaluate our process and determine where they could make improvements to prevent this from happening again.
- Query other hospitals in the state about their process.
- Agree that it would be beneficial for patients to be put in hospital pajamas upon arrival to the Assessment Unit (AU).
- Continue to learn of best practices and determine how to change their policy.
- Fire event review with safety department to review emergency response (fire alarm, sprinkler and the use of a fire extinguisher).

3. Record review of the facility's "Psychiatric Center Operations Meeting Agenda," dated 02/19/18, (eight days after the fire occurred), showed the following:
- Continued to take into consideration ways to have patients change clothes and search for contraband.
- If they put everyone in pajamas, then they would have to provide underwear/bras.
- Continued to query five other psychiatric hospitals in the state for their processes.
- Evacuation training for staff scheduled for 02/23/18 (12 days post fire) and 02/26/18 (15 days post fire).

4. Record review of an email from the manager of Patient Safety and Risk Management to Staff A, Patient Safety Performance Improvement Coordinator, dated 02/15/18, showed that she had notes from various conversations that she wanted her to have so she could ponder them.

5. Review of the facility's policy, "Patient Belongings and Valuables-Guideline" dated 09/16/16, showed the purpose was to control what patient property is allowed on University of Missouri Psychiatric Center (MUPC) inpatient units for safety of patients and staff as well as to prevent loss of patients' property as:
- Contraband is not allowed in the MUPC facility;
- Items that are considered contraband are: knives, guns, ammunition, fireworks, alcohol, illegal substances or any other item deemed to be dangerous;
- Items that may be stored on the unit but not allowed in patient's baskets are glass, sharps, razors, cigarettes (e-cigarettes and vapor cigarettes) and lighters should be sent home with family;
- Admission to inpatient unit the Mental Health Technician (MHT) will search all patients' belongings for contraband;
- The MHT will also look through the patient's bags, purses, and/or suitcase for valuables or items that must be locked in the safe, list them on the belongings checklist and include these items in the envelope to go to the safe; and
- The MHT will also separate those items that should be locked separately ON THE UNIT (sharps, glass, cigarettes, lighters, etc.) into another envelope.

6. Record review of Patient #1's psychiatry notes, dated 02/09/18, showed that he was a 36 year old male was admitted to the facility on 02/09/18. He had significant history of substance induced mood disorder (elevation or lowering of a person's mood by drugs), cannabis abuse, and antisocial personality disorder (disregard for other people), and multiple suicide attempts, last attempt 2011, when the patient was in jail. He was admitted to the fourth floor medical on a 96 hour hold, after the patient was found by police behaving in an erratic and violent manner. On arrival he required as needed medications (PRN) for agitation as well as restraints. He was noted to have sustained tachycardia (fast heart beat) with elevated Creatine Kinase (CK, enzyme found in heart muscle, levels released in blood may indicate muscle damage) level and thus was admitted to the medical floor. Since admission he had remained calm and cooperative per nursing report and would be admitted to Behavioral Health Unit (BHU). Given the patient's symptoms, concerns from collateral, lack of medications, or outpatient support, it appeared that the patient was at imminent risk for harm to himself and to others, and further at risk for misinterpreting his environment. The plan was to admit to the BHU, two north, on a 96 hour hold. He would be placed on suicide observation (SO), assault observation (AO), and started on medication with a plan to transition to LAI (long acting injection) as compliance had been an issue. The facility would provide a safe, supportive and structured environment.

Record review of the facility's undated algorithm "Care Guidelines for 96 Hour Holds and Potential Holds " showed that in the ED, patients that were suicidal/homicidal/acutely psychotic, were to be changed into red paper scrubs/gown, belongings removed from room, and complete the room checklist to ensure environmental safety. Patients that were in-patient care or admitted from the ED, should follow the 96 hour hold pathway for placing the patient in red paper scrubs/gown, belongings removed from room, and the completion of the room checklist to ensure environmental safety.

Record review of Patient #1's client belongings checklist, dated 02/09/18 at 4:30 PM, showed items kept with the patient on admission to the BHU were:
- Tennis shoes without laces;
- Three socks;
- One sweat shirt; and
- One long sleeve shirt.

Record review of Patient #1's fourth floor nurse's note, dated 02/09/18 at 4:36 PM, showed that:
- Patient #1 ripped out intravenous catheter (IV, small plastic tube placed in vein to administer medication or fluids), and threw telemetry box (portable box attached to patients to monitor heart rate) across the room.
- The patient walked to the elevators where he was escorted by security back to his room;
- Report was given to BHU two north; and
- The patient was escorted by wheelchair to the BHU.

Review of the facility's video recording, dated 02/09/18, from 3:38 PM to 3:51 PM, showed:
- Patient #1 was placed in a wheelchair (WC) escorted by two security guards and one staff nurse and transferred from the fourth floor medical to two north BHU;
- The patient had on street clothes (purple sock cap, blue coat, multi-layer shirts, blue, yellow, white, white pants, and tan color nonskid socks);
- The patient entered two north BHU, escorted by staff, with his street clothes (white long sleeve shirt, white draw string pants); and
- The patient was in the day room with street clothes on.

During an interview on 02/22/18 at 3:55 PM, Staff LL, Mental Health Technician (MHT), stated that:
- He remembered Patient #1's arrival to the BHU;
- He escorted the patient from the exam room into the dayroom to do vital signs because he did not like using the vital sign machine in the exam room;
- The patient walked over to the dayroom and Staff LL took the patient's belongings to the nurse's station to complete the belongings check list;
- He could not remember what the patient was wearing, but if he was a psychiatric patient on the medical floor, the patient should have had a red gown or red paper scrubs on;
- He did not search the patient for contraband;
- After sitting in the dayroom, the patient got up and walked to his room, with the same clothes he left the medical floor with, and laid down on his bed;
- Staff LL entered the patient room and placed the BHU pajamas next to his bed;
- He did not have the patient change into the BHU pajamas from the clothes that he entered the unit in; and
- He had not had any education on contraband checks or fire drills since the fire.

During a telephone interview on 02/21/18 at 2:16 PM, Staff W, MHT, stated that:
- She remembered Patient #1's arrival to the BHU;
- She did not check for contraband;
- Nursing staff was not responsible for checking patients for contraband; and
- Security performed the search on patients.

Observation on 02/21/18 at 10:25 PM, BHU second floor, showed:
- The floor was rectangle shape with two units (two north, two south) at each end;
- In front of each unit, was the elevator and a stairwell (two north and two south stairwell);
- Each stairwell was identical, from second floor there were eleven steps down to a landing that turned to eleven steps that led to the first floor (22 steps total);
- Next to the north stairwell was a room that stored a med sled (evacuation sled that enabled staff to transport a patient down a stairwell) and a Evacuation chair (device manufactured to descend down the stairwell in an emergency, which required no heavy lifting) that were used in an evacuation of non ambulatory patients;
- Next to the south stairwell was a room that stored a hard back board (board that immobilized and lifted patients) and a soft back board (identified by staff as "taco"); and
- Tracing the evacuation route, staff and patients evacuated from the north unit to the south elevator and stairwell hallway for refuge behind the fire wall.

Record review of the facility's emergency response manual showed the standard response for staff in a focused event evacuation were as follows:
- Horizontal evacuation was completed first in an event;
- Vertical evacuation began with those in immediate danger that required the least resources to move; and
- Med sleds and evacuation kits were pre-deployed in multiple locations.

During an interview on 02/22/18 at 3:00 PM, Staff II, Registered Nurse (RN), stated that:
- She was working on two north BHU the day of the fire;
- She was at the nurse's desk and saw across the day room, smoke and an amber glow from Patient #1's room;
- The staff gathered the patients and evacuated to the south stairwell;
- There were three non ambulatory patients, one in a WC, one in a motorized WC, and one with a wheeled walker;
- The patient with the wheeled walker was assisted down the stairs;
- The patient in the WC, Staff UU, MHT, placed on his back and carried him down the stairs;
- The patient in the motorized WC was placed on a soft backboard "taco" and carried down the stairs;
- She had not had any training/education on fire drills or contraband since the fire;
- It was not nursing's responsibility to check for contraband; and
- Security was responsible to keep the patients and staff safe.

During an interview on 02/22/18 at 10:20 AM, Staff UU, MHT, stated that:
- He was working on two south BHU the day of the fire;
-The med sled and chair sled was by the north stairwell, and did not want to go towards the fire to get them;
- He picked up the patient in the WC, placed him on his back and carried the patient down the stairs;
- They accessed a hard backboard, but "it took too much time to turn it around corners";
- From this facility he had never had any fire training that instructed him to carry patients on your back;
- Security wands (portable device that scans for metal objects) patients for contraband and it was not the MHT's responsibility to "pat down" the patients for contraband;
- He had one patient that brought a razor blade into the unit;
- He had not had any training/education on fire drills or contraband checks since the fire; and
- After the fire, Patient #1 told him that he got the lighter into the BHU by placing it under his wrist band and walked in with it.

Record review of an untitled document, provided by Staff WW, Manager of Regulatory, showed there were a total of eight incidents of contraband found on the BHU in 2017.

During an interview on 02/22/18 at 10:40 AM, Staff I, Security, stated that:
- He was working the day of the fire;
- He was present when Law Enforcement interviewed Patient #1 after the fire;
- The patient stated that he was attempting to light a cigarette under the mattress with a lighter when the mattress caught on fire;
- When patients were a 96 hour hold they should not have their own clothing, they should be in red paper scrubs; and
- The facility had not performed any fire drills since the fire because the "fire counted as a drill."

Review of the facility's video recording of the second floor MUPC dated 02/11/18, from 1:27 PM to 1:44 PM, showed the following:
- Patient #1 walked out into the hallway with smoke and an amber glow that was seen from his room;
- Staff gathered the patients and evacuated the unit;
- Staff, ambulatory patients and three non ambulatory patients, one in a wheelchair, one in a motorized wheelchair, and one with a wheeled walker congregated at the corridor of the two south stairwell;
- The patient with a wheeled walker ambulated to the stairwell with assistance;
- The patient in the wheelchair clasped his hands around Staff UU's neck and was carried to the stairwell on Staff UU's back; and
- The patient in the motorized wheelchair was placed on a soft backboard, "taco," safety straps dangled to the side and carried to the stairwell by staff.

Record review of the facility's undated post event interview with Staff VV, MHT, showed:
- He was making rounds when the alarm went off;
- He saw smoke and smelled smoke;
- There were three non ambulatory patients;
- Patients were large and heavy, "Hurt back"; and
- Admission Unit (AU) appeared not to screen or search very well, and past history of "blades" in backpacks or clothes that get into the unit.

Record review of the facility's undated post event interview with Staff UU, MHT, showed:
- He saw patient from two north outside the unit;
- He attempted to get the patient back to the unit, then saw smoke;
- There were three non-ambulatory patients; and
- He carried one patient on his back, and one on a stretcher.

Record review of the facility's undated post event interview with Staff II, RN, showed:
- She was standing at the desk and heard crackling and saw an amber glow;
- She had issues with Patient #1 earlier; and
- had three non ambulatory patients, one in power chair, one with walker, and one with wheelchair.

Record review of Patient #1's psychiatry notes, dated 02/13/18, showed on the evening of 02/11/18 nursing staff observed the patient walk out of his room with flames and smoke behind him. The patient was discharged and transferred to Law Enforcement for jail confinement due to charges related to the fire he set on the unit.

During an interview on 02/22/18 at 4:10 PM, Staff AA, Chief Nursing Officer (CNO), stated the following:
- She was responsible for all of the nursing staff;
- On 02/11/18, a patient on the second floor of MUPC started a fire in his room with a lighter;
- She did not know how Patient #1 got contraband into the unit to start the fire;
- A plan of action had not been put into place;
- Her expectation of nursing staff and security was to physically look for contraband and wand all patients admitted to the MUPC;
- Her expectation of nursing staff was to use the med sled and chair to evacuate patients during a fire;
- It was not safe practice for staff to carry patients on their backs to evacuate and should not be done; and
- There have been no fire drills or staff education since the fire occurred on 02/11/18.

The facility failed to assure that staff were trained both in prevention of contraband brought onto the unit and appropriate fire safety evacuation for non-ambulatory patients. The facility also showed no urgency to formulate an action plan post event, which placed all patients in the hospital at risk for injury or death.


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