HospitalInspections.org

Based on observations, policy review, and staff interview (EMP), it was determined the facility failed to keep the patient safe by not completing oxygen therapy education per policy and not posting "No Smoking" signs in areas where oxygen is used.


Findings include:


On October 29, 2025, a review of the "AHN Medical Staff Rules and Regulations" last approved 03/2024, revealed: "... There shall be no smoking on campus. ...".


On October 29, 2025, review of facility policy "Oxygen Therapy", last approved 08/2025, revealed: "... Provide oxygen to patients requiring oxygen therapy and have it administered safely ... The hospital strictly enforces its policy as a non-smoking facility. ... The precautions with oxygen administration include the following: ... Inform the patient and any occupants in the room of the "No Smoking" hospital policy and explain the presence of oxygen rapidly accelerates combustion and that smoking in the presence of oxygen is hazardous. ..."


On October 29, 2025, at approximately 9:30 AM, during an interview, EMP2 stated that on October 24, 2025, at approximately 1:30 AM, a fire occurred in ED patient room 7, while the patient was on 3 liters of oxygen by nasal cannula. At the time of the event, there were no "No Smoking" signs. EMP2 further explained that during review of the event, the patient's lighter was determined to be the source of a fire.


On October 29, 2025, at approximately 11:15 AM, during tour of facility's imaging area, wall-mounted oxygen was noted in the CT scanner room and in the X-ray room. However, there were no "No Smoking" signs visible anywhere in this area.


On October 29, 2025, at 12:15 PM, an interview was held with EMP14 and revealed that on October 24, 2025, at approximately 01:00 A.M., the patient (MR1) was placed on 3L oxygen. About an hour later, EMP14 found MR1 in the bed patting her face. She had flames on her head and she was holding her lighter which was on fire. The tubing from the oxygen was up around her ears and it was sparking. EMP14 quickly removed the oxygen tubing from MR1's head, shut off the oxygen supply at the wall, and used blankets to put the fire out on MR1's head and the bed. When asked if EMP14 provided any education to MR1 about flammability of oxygen and the importance of avoiding open flame or smoking, EMP14 replied they did not provide oxygen therapy education to the patient.


On October 29, 2025, at approximately 9:30 AM and at 11:15 AM, EMP2 confirmed the failure to post no smoking signs.


On October 29, 2025, at 12:25 PM, EMP14 confirmed the failure to educate the patient.

Based on review of facility documents and staff interviews (EMP), it was determined the facility failed to maintain written evidence of regular inspection and approval by State or local fire control agencies.

Findings include:

Review of facility policy "Building, Fire, Fire Equipment, and Smoke Barrier Protection", last approved 10/2024, revealed: " ... It is the policy of this Hospital to comply with all local, state, and federal laws to ensure building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat and to ensure that fire safety equipment and fire safety building features are inspected and maintained in accordance with NFPA® standards. ...".

During interview with EMP2 on October 29, 2025, at approximately 1:00 PM, EMP2 stated the facility opened in March 23, 2020. Review of facility documentation revealed no written evidence of regular inspection and approval by State or local fire control agencies since the facility opened.

During an interview on October 29, 2025, at approximately 1:00 PM, EMP2 confirmed the above.