The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

TENNOVA HEALTHCARE 900 EAST OAK HILL AVENUE KNOXVILLE, TN 37917 May 25, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical record review, review of facility documentation, observation, and interview, the facility failed to provide care in a safe setting for 1 patient (#1) of 4 patients reviewed for restraints.

The findings inculded:

During the survey it was found one patient (#1) with a history of alcoholism, dementia, and [DIAGNOSES REDACTED] was placed in restraints after the patient was found to be confused. The patient had a cigarette lighter in the room which had not been removed by staff. The patient subsequently used the lighter and lit paper while in the bed, resulting in a fire in the patient's room and burns to the patient, which required transfer to a Burn Center.

During a conference on 5/16/16 at 4:00 PM, in the conference room, with the Administrator, Chief Nursing Officer (CNO), Director of Quality Management, and the Metro Director of Quality Management, the facility was informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause injury, harm, impairment, or death) at CFR Part 482.13 Patient's Rights (Condition).

Review of an Immediate Action Plan (MDS) dated [DATE] revealed the following actions were implemented:
(1) Physical Restraints: dated 5/16/16
1. Education/key points were developed for nursing staff regarding the restraint policy, including but not not limited to:
Restraints are a last resort when other methods of preventing injury to patients or other are not effective
Restraint orders must include the type of restraint, reason for restraint, alternative attempted, and criteria for discontinuation
For all patients in restraints assess the environment to ensure patient does not have access to potentially dangerous items, such as cigarette lighter
2. Nursing staff were educated on these key points, and the restraint policy was reviewed during live sessions. Also during these live training sessions, re-education was given on tying restraints, with return demonstration required for validation of competency. Dated 5/16/16 and ongoing.
3. An audit tool was developed for utilization by the nursing leaders/designees to track each patient in a restraint until the restraint is discontinued. The audit tool covers shift assessment and documentation requirements, requirements for every 2 hour assessment and documentation, restraint application, and confirmation that the patient's belongings have been removed from the room and that the environment is free from potentially dangerous items. Revised 5/17/16.
4. The audit tool was initiated and completed on 100% of patients in restraints to ensure documentation requirements are met, restraints are applied correctly, and that the restrained patient's environment is free from potentially dangerous items. Dated 5/16/16.
5. Audit results are provided to the Chief Nursing Officer, along with any encountered issues, which are addressed immediately and required follow-up completed. Dated 5/16/16 and ongoing.
6. A report on unit-specific restraints and audit results is presented by the nursing leaders during the daily facility safety huddle/nursing huddle. Began reporting unit-specific restraints in 2015, and began reporting additional detail on audit results 5/18/16 and ongoing.
7. Audit results will be reported through the facility Quality/Safety Committee beginning with June 2016 meeting.

(2) Patient supervision/patient belongings
1. Education/key points were developed for nursing staff regarding the Patient Belongings and Search Policy, to include the following:
The patient inventory list is to be completed on all admissions to the inpatient units. Plan dated 5/16/16
Any items not sent home are to be inventoried and listed.
Any items (contraband, valuables, medicines, weapons, etc.) that are stored and/or confiscated by the hospital must be listed on the Patient Inventory List, labeled and signed by both a staff member and the patient.
Patients are to verify collection of all items and to sign the form on admission even if no items are collected
2. Nursing staff were educated on the Patient Belongings and Search policy key points by their unit leaders and during their unit safety huddles. Dated 5/16/16 and ongoing.
3. A decision was made to remove patient belongings from a patient's room: if a patient is in restraints; or if a patient exhibits any mental status changes- such as confusion- whether or not the patient is in restraints. Dated 5/17/16.
4. An audit tool was developed for utilization by the nursing leaders/nursing units to track compliance with completion of the Patient Inventory List upon patient admission. Dated 5/13/16.
5. The audit tool was initiated and completed on 100% of patients to ensure each patient's Patient Inventory List was completed. For any patient who did not have a belongings sheet in place the belongings inventory was immediately completed and filed on the patient's chart. Dated 5/13/16 and ongoing.
6. Audit results are provided to the Chief Nursing Officer, along with any encountered issues and required follow-up completed. Dated 5/13/16 and ongoing.
7. A report on patient belongings compliance is presented by the nursing leaders during daily facility safety huddle/nursing huddle. Dated 5/18/16 and ongoing.
8. Audit results will be reported through the facility Quality/Safety Committee.

(3) Observations and Interviews
Observation on 5/17/16 at 7:40 AM at Building A, in the education dining room, revealed employee training for restraints, procedure for assessing and securing patient belongings, and the use of fire extinguishers was being provided for the facility employees.

Observation of a Staffing Huddle at Building A on 5/17/16 at 9:30 AM, on the CPU (cardiopulmonary unit), revealed the unit manager conducting a brief meeting with unit's staff regarding staffing and patient discharges. Further observation revealed the facility's restraint policy and patient belonging policy was reviewed and the staff were given the dates to attend the facility's mandatory training for restraints and patient belongings.

Observation on 5/18/16 at 8:00 AM at Building A, in the education dining room, revealed employee training for restraints, procedure for assessing and securing patient belongings, and the use of fire extinguishers was being provided for the facility employees.

Observation on 5/18/16 at 11:45 AM at Building A, in the Nursing Conference room, of a facility wide safety huddle in which all department managers attend, revealed the administrative staff discussed the mandatory employee training for restraints, patient belongings and fire extinguishers.

Observation on 5/18/16 at 12:00 PM at Building A, in the Nursing Conference Room, of a Nursing Clinical Huddle conducted by the CNO, revealed all nursing unit mangers attend the daily meeting. Further observation revealed the policies regarding restraints and patient belongings were reviewed. Further observation revealed a quality management tool regarding the use of restraints for each unit was reviewed and discussed. Further observation revealed the unit managers are reviewing all patient medical records to ensure the patient belonging form is being filled out and all patient belongings are secured or noted in the medical record. Further observation revealed auditing tools for the use of a restraint and patient belongings were reviewed and these tools are completed by the managers, brought to the CNO, and then forwarded to the Quality Management.

Observation on 5/19/16 at 1:15 PM at Building B, in the dining room, revealed employee training for restraints, procedure for assessing and securing patient belongings, and the use of fire extinguishers was being provided for the facility employees.

Interview with the Risk Manager at Building C on 5/21/16 at 9:00 AM, in the conference room, revealed the facility had implemented the Metro mandatory training for employees regarding restraints, patient belongings and fire extinguishers.

Facility documentation revealed 96% of Building A had completed the training, 88.64% at Building B and 89.69% at Building C. Facility documentation revealed Building B and Building C had deployed the "Train the Trainer Model" and all departments have their trainers and a central education log sheet is on the shared drive. The log is updated daily and each manager is accountable to provide the hands on training to each team member prior to working any upcoming shift. Once the training had occurred the manager is accountable to update the education log and send sign in sheets to the Quality Department.

The action plan for the Fire which occurred on 5/10/16 was presented 5/25/16 at 10:15 AM by the Director of Quality Management and the Metro Director of Quality Management, in the conference room. The facility implemented the action plan and the plan was reviewed and verified as described above. The immediacy was removed on 5/25/16.

Refer to Standard A144 and A167.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical record review, review of facility documentation, observation, and interview, the facility failed to provide care in safe manner for one patient (#1), who was restrained, of 4 patients reviewed for restraints.

The findings included:

Review of facility policy, Patient Belongings and Search Policy #4264, last reviewed on 11/9/15, revealed "...it is the policy of [facility] to maintain written procedures for the inventory and storage of patient belongings and valuables...all staff from the point of presentation have the responsibility to inventory belongings, valuables and contraband...the patient inventory list form must be completed...contraband items will be handled in the following manner when brought to the unit: dangerous items such as weapons will be either sent home with the patient's family/friend/significant others or sent to security..."

Medical record review revealed Patient #1 was admitted to the facility on [DATE] with diagnoses including Metabolic Acidosis (a condition that occurs when the body produces excessive acid in the body fluids), Alcoholism, History of Ricketts (a softening and weakening of the bones usually due a Vitamin D deficiency), Chronic Pancreatitis, and acute Kidney Injury. Further review revealed the patient had a past history of Dementia felt to be related to alcohol. Further review revealed the patient was transferred to another acute care facility on 5/11/16.

Medical record review of an Admission History and Physical dated 5/8/16 revealed "...admitted with history of chronic alcoholism...pancreatitis...dementia related to alcohol..."

Medical record review of a Nursing Admission History form dated 5/8/16 at 3:39 PM revealed "...patient belongings: clothing money, other annotate...disposition of belongings: with patient..." Further review revealed no patient belonging valuables checklist in the patient's medical record.

Medical record review of a Nurse's Note dated 5/10/16 at 2:00 PM revealed the patient was "...pulling out tubes...confused..." Further review revealed the patient was placed in soft wrist restraints on 5/10/16 at 2:30 PM.

Review of a Code Red (code for fire) report revealed the fire alarm was activated on 5/10/16 at 5:38 PM for the patient care area and room where Patient #1 was located.

Medical record review of an ED Physician Consult Progress Note dated 5/10/16 at 7:00 PM revealed "...pt. [patient] is inpt. [inpatient] victim of burns...dropped his keys then lit a piece of paper on fire...was in restraints by report..."

Medical record review of a Critical Care Note dated 5/10/16 at 7:00 PM revealed "...on the floor with metabolic [DIAGNOSES REDACTED] secondary to ETOH [alcohol] abuse and lit a piece of paper on fire which then fell into the bed. Now with 60% body surface burns..."

Review of an Investigation Summary Worksheet dated 5/10/16 revealed "...5/10/16 the patient exhibited inappropriate behaviors and confusion, to include pulling at this midline catheter [catheter in peripheral artery for medication administration]...the physician was called and the patient was placed in soft wrist restraints at 2:30 PM..." Further review revealed "...at 5:38 PM the staff responded to a call bell request...found his mattress and blanket on fire..." Further review revealed "...per patient's self-report the emergency room Nurse...he had lit a piece of paper on fire in order to look for his keys, and the paper fell on to the bed, starting the fire..." Further review revealed the patient was taken to the Emergency Department for evaluation and treatment after the fire. Continued review revealed "...the patient sustained 60% of BSA [body surface area] of 3rd degree burns from this fire. Involved areas included: head and neck; trunk-extensive anterior, and some areas on posterior; left arm and left hand- extensive; left leg- medial and lateral areas; right arm and right leg-small areas..."

Review of a photo from the Fire Department with no date or time, which was taken after the incident revealed a cigarette lighter which was found in the patient's bed after the incident on 5/10/16.

Observation of the patient's bed involved in the fire on 5/11/16 at 3:32 PM, revealed major damage observed to the left side of the bed, and charred burns observed to the left side rail. Further observation revealed a soft wrist restraint still attached to the lower frame of the right side of the bed and a soft wrist restraint hook to the left side of the bed. Further observation revealed water leaking from the mattress of the bed.

Interview with the Nurse Manager for the unit where the fire originated on 5/11/16 at 1:50 PM, in the conference room, revealed "...they found a cigarette lighter in the room and the lighter was removed from the room by the fire investigator which was thought to have been the source of the fire..."

Interview with CNA (Certified Nurse Assistant) #1 on 5/11/16 at 4:05 PM, in the conference room, revealed "...when the patient came in Saturday night I was working, his clothes were nasty and we cleaned him up...he had a wad of money and would not let us lock it up...we put the money, coins, a cigarette lighter and his keys in a bag and left them in the room with the patient...the bag had been laying in the table the whole time..." Further interview revealed "...the patient was placed in restraints earlier in the shift on [5/10/16] and they were loosely applied to his hands...he was confused and wanted me to give him a knife to cut them off..."

Interview with RN (Registered Nurse) #1 on 5/11/16 at 4:15 PM, in the conference room, revealed the RN was the patient's primary care nurse on 5/10/16. Further interview revealed "...the patient was confused...we had to put soft wrist restraints on him earlier in the afternoon because he was trying to pull his IV's [intravenous line for medication administration] out and getting out of the bed...the restraints were applied loosely just to keep him from pulling his IV's out..." Further interview revealed "...when we put the restraints on the patient he had a lighter in the room..."

Telephone interview with RN #2 on 5/12/16 at 9:10 AM revealed the RN admitted the patient to the unit on 5/8/16. Further interview revealed "...I charted the patient had money and clothing and was going to make a note of something else but I did not make an annotated note...I did not fill out the patient belonging list...he had money and keys in a plastic bag...I did not know about the lighter..."

Interview with the Chief Nursing Officer (CNO) on 5/12/16 at 10:20 AM, in the conference room, revealed "...if a patient is a Psychiatric patient we would take the lighter from the patient...I think I would have taken the lighter from the patient initially but definitely when the patient had signs of confusion..." Further interview revealed "...the policy says that patients' belongings should be inventoried and if necessary be secured in the security department's safe...there is no Patient Inventory Form on the patient's chart..."

Interview with the Risk Manager on 5/18/16 at 1:30 PM, in the conference room, revealed "...for any patient who had dementia a lighter should have been removed from the room at that time..." Further interview confirmed there was unsafe not removing the lighter once the patient was confused and placed in restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical record review, review of facility documentation, observation, and interview, the facility failed to use safe restraint techniques for 1 patient (#1) of 4 patients reviewed for restraints.

The findings included:

Review of facility policy, Rights and Responsibilities, last revised on 1/15/16, revealed "...the resident has a right to the following: (h) to be free from chemical and physical restraints..."

Review of facility policy, Restraints, last review 9/6/13, revealed "...definitions [1] restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely..." Further review revealed "...monitoring and assessments shall occur at least every 2 hours and documented on all patients in restraints...alternatives: alternative to and less restrictive forms of restraints considered by the caregiver should be documented at least once per shift...[iv] other monitoring: other monitoring activities should be performed at least every 2 hours, or more frequently if indicated by the condition or behavior of the patient. During monitoring, the patient should be assessed for: signs of any injury associated with the use of restraint, nutrition and hydration needs...circulation, hygiene, and elimination...physical and psychological status and comfort..."

Medical record review revealed Patient #1 was admitted the facility on 5/8/16 with diagnoses including Metabolic Acidosis (a condition that occurs when the body produces excessive acid in the body fluids), Alcoholism, History of [DIAGNOSES REDACTED] (a softening and weakening of the bones usually due to a Vitamin D deficiency), Chronic Pancreatitis, and Acute Kidney Injury. Further review revealed the patient had a past history of Dementia, felt to be related to alcohol. Further review revealed the patient was transferred to another acute care facility on 5/11/16.

Medical record review of an Admission History and Physical dated 5/8/16 revealed "...history of chronic alcoholism. He also has a history of [DIAGNOSES REDACTED] as a child with severe scoliosis and chronic pain. Previous records indicate a history of chronic pancreatitis and dementia related to alcohol..." Further review revealed "...in the Emergency Department, the patient was found to have a metabolic acidosis...awake and alert, mildly confused..." Further review revealed "...assessment and plan: (1) metabolic acidosis...suspect alcoholic ketoacidosis along with a component of lactic acidosis...(2) alcoholism...(5) history of chronic pancreatitis secondary to alcoholism...(6) history of dementia felt to be related to alcohol..."

Medical record review of an admission History assessment dated [DATE] at 3:29 PM revealed "...patient belongings: clothing, money, other annotate...disposition of belongings: with patient..."

Medical record review of a Nurse's Note dated 5/9/16 at 7:51 AM revealed "...psychosocial: mood/affect: patient...anxious...behavior: apprehensive..."

Medical record review of a Nurse's Note dated 5/10/16 at 2:00 PM revealed "...pt.[patient] pulling out tubes...up in room walking in blood...dr. [doctor] called for restraints...neurological: LOC [level of consciousness], confused..." Further review revealed at 2:30 PM "...restraint initial, done...soft wrist...reason ordered: lines and tubes..." Further review revealed at 4:30 PM "...soft wrist restraint... RN [Registered Nurse] assessment continued..."

Medical record review revealed a Restraint Order dated 5/10/16 at 2:30 PM was given by the physician.

Review of a Code Red (code for fire) report dated 5/10/16 at 5:38 PM revealed a notification of a fire alarm activation. Further review revealed "...we have a fire room [patient #1's room]..."

Medical record review of an Emergency Department (ED) Physicians Consult Progress Note dated 5/10/16 at 7:00 PM revealed "...Pt.is inpt [inpatient] victim of burns, he dropped his keys then lit a piece of paper on fire. Denies SI [suicidal ideations]...was in restraints by report..."

Medical record review of a Critical Care Note dated 5/10/16 at 7:00 PM revealed "...on the floor with metabolic [DIAGNOSES REDACTED] secondary to ETOH [alcohol] abuse lit a piece of paper on fire which then fell on to the bed. Now with 60% body surface burns..."

Medical record review of a Pulmonary Critical Care Medicine Consult note with no date or time revealed "...called emergently to evaluate pt. that burned himself on floor..." Further review revealed "...[1] severe 60% BSA [body surface area] third degree burns...volume resuscitation ongoing...transfer to [named burn center]...[2] acute respiratory failure after burns ? [questionable] inhalation injury....on ventilator..."

Review of an Investigation Summary Worksheet dated 5/10/16 revealed "...was subsequently admitted to a general medical floor with a diagnosis of [DIAGNOSES REDACTED]] and chronic pancreatitis. The patient was alert and oriented from the time of his admission until the afternoon of 5/10/16- at which time he exhibited inappropriate behavior and confusion- to include pulling at his midline catheter [intravenous line to administer medications]. The physician was notified and the patient was placed in soft wrist restraints for line protection at 2:30 PM..." Further review revealed "...at approximately 5:38 PM, staff responded to the patient's call bell/request for assistance, and found his mattress and blanket on fire..." Further review revealed "...staff began to evacuate the involved patient to the Emergency Department...per the patient's self-report to the emergency room Nurse during the intake process, he had lit a piece of paper on fire in order to look for his keys, and the paper fell on to the bed, starting the fire..." Further review revealed "...the patient sustained 60% of BSA 3rd degree burns from this fire..."

Observation of the patient's bed involved in the fire on 5/11/16 at 3:32 PM revealed major damage observed to the left side of the bed, and charred burns observed to the left side rail. Further observation revealed a soft wrist restraint still attached to the lower frame of the right side of the bed and a soft wrist restraint hook to the left side of the bed. Further observation revealed water leaking from the mattress of the bed.

Interview with the Nurse Manager for the unit where the fire originated on 5/11/16 at 1:50 PM, in the conference room, revealed "... the patient was placed in soft wrist restraints on 5/10/16 around 2:15-2:30 PM due to pulling his IV [intravenous catheter for medication administration] out..." Further interview revealed "...they found a lighter in the room and the lighter was removed from the room by the fire investigator, which was thought to have been the source of the fire..." Further interview revealed "...the patient suffered injuries to his face, Left arm, left chest..."

Interview with ED RN #1, who was present when the patient arrived in the ED, on 5/11/16 at 2:40 PM, in the ED conference room, revealed "...the patient was brought to the ED by the ICU [Intensive Care Unit] nurse and another male...the bed was charred and the mattress was burned...he had burns to the left shoulder, left anterior chest, his face and the hair to his left side of the head was singed..." Further interview revealed "...he had taken a piece of paper and lit the paper with a cigarette lighter to find his keys...he used a lighter to light the paper...his left arm was in a restraint which was melted from the fire..."

Interview with ED Physician #1, who treated the patient on 5/10/16 in the ED, on 5/11/16 at 3:00 PM, in the ED conference room, revealed "...the patient was brought to the ED...he said 'I dropped my keys next to my mattress and could not see'...he said he lit a paper to be able to see to find the keys...he was in the hospital for delirium..." Further interview revealed "...his cognitive status was just not right...it seemed odd..." Continued interview revealed "...he had 3rd degree burns to his left arm, left chest, thigh, face, ear and cheek..."

Interview with Certified Nurse Assistant (CNA) #1 on 5/11/16 at 4:05 PM, in the conference room, revealed the CNA was working on the medical surgical unit where the fire occurred on 5/10/16. Further interview revealed the CNA had been in the patient's room 5 minutes prior to the fire. Continued interview revealed "...he was wearing restraints to both hands...he had pulled his IV's out prior...the restraints were just loosely applied to his hand...he was confused and wanted me to give him a knife to cut the restraints off to go to the store..." Further interview revealed "...he hollered at us all when we would go by the room wanting us to come in his room and cut the restraints off...the last time I seen him in the room he was confused..." Continued interview revealed "...I walked down the hall toward his room...I saw smoke when I rounded the corner and when I stepped into his room the bed was on fire..."

Interview with RN #1 on 5/11/16 at 4:15 PM, in the conference room, revealed the nurse was the patient's primary nurse and the day shift charge nurse on the unit where the fire occurred. Further interview revealed "...the patient was confused and we had put soft wrist restraints on him earlier in the afternoon because he was trying to get of the bed and pulling his IV's out..." Continued interview revealed "...he had a lighter in the room...I talked with the patient prior to the fire and told him because he was pulling his IV's out that we had to put the restraints on him...he was confused and not intact...he was just not right when you talked to him..." Further interview revealed "...the wrist restraints were applied loosely just to keep him from pulling his IV's out..." Further interview revealed "...we were in the medication room and the fire alarm went off...I heard someone scream for help and when I walked out of the medication room I saw smoke in the hallway...[named CNA] was in the room with the patient trying to put the fire out..."

Interview with the Chief Nursing Officer [CNO] on 5/12/16 at 10:20 AM, in the conference room, revealed "...I am concerned about the restraints being applied loosely for the patient...if the patient needed restraints from pulling IV lines out then they should not be applied loosely..." Further interview revealed "...I think I would have taken the lighter from the patient initially but definitely when the patient had signs of confusion..."

Telephone interview with the Hospitalist on 5/16/16 at 1:01 PM, revealed the physician had examined the patient on 5/10/16 during the morning. Further interview revealed "...later that day he became agitated when they called me around 3:00 PM or 4:00 PM...they said he was agitated and wanting to leave..." Continued interview revealed "...he was pulling his IV's out and they asked for an order for restraints and I did give them an order for soft wrist restraints..."

Interview with the facility's Risk Manager (RM) on 5/18/16 at 1:30 PM, in the conference room, revealed "...the patient had been placed in soft wrist restraints around 2:30 PM on 5/10/16...he was admitted with metabolic acidosis, alcohol related dementia and had [DIAGNOSES REDACTED] related to the alcohol..." Further interview revealed "...the restraints were placed on the patient due to patient pulling out his IV lines and confusion...he did have a history of dementia..." Continued interview revealed "...for any patient who had dementia the restraint should have not been applied loosely, they should be applied correctly..." Further interview confirmed the physical restraint was not applied correctly and the lighter was not removed when the patient was confused and placed in restraints.
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, review of facility documentation, medical record review, observation and interview, the facility failed to provide nursing services to prevent injury for 1 patient (#1) of 4 patients reviewed for restraints.

The findings included:

During the survey it was found one patient with a history of alcoholism, dementia, and [DIAGNOSES REDACTED] was placed in restraints after the patient was found to be confused. The patient had a cigarette lighter in the room. The patient subsequently used the lighter to light a paper while in bed, resulting in a fire in the patient's room and burns to the patient, which required transfer to a Burn Center.

During a conference on 5/16/16 at 4:00 PM, in the conference room, with the Administrator, Chief Nursing Officer (CNO), Director of Quality Management, and the Metro Director of Quality Management, the facility was informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause injury, harm, impairment, or death of a patient) at CFR Part 482.23 Nursing Services (Condition).

Review of an Immediate Action Plan (MDS) dated [DATE] revealed the following actions were implemented:
(1) Physical Restraints: dated 5/16/16
1. Education/key points were developed for nursing staff regarding the restraint policy, to include, but not limited to:
Restraints are a last resort when other methods of preventing injury to patients or other alternatives not effective
Restraint orders must include the type of restraint, reason for restraint, alternative attempted, and criteria for discontinuation
For all patients in restraints assess the environment to ensure patient does not have access to potentially dangerous items, such as cigarette lighter
2. Nursing staff were educated on these key points, and the restraint policy was reviewed during live sessions. Also during these live training sessions, re-education was given on tying restraints, with return demonstration required for validation of competency. Dated 5/16/16 and ongoing.
3. An audit tool was developed for utilization by the nursing leaders/designees to track each patient in a restraint until the restraint is discontinued. The audit tool covers shift assessment and documentation requirements, requirements for every 2 hour assessment and documentation, restraint application, and confirmation that the patient's belongings have been removed from the room- and that the environment is free from potentially dangerous items. Revised 5/17/16.
4. The audit tool was initiated and completed on 100% of patients in restraints to ensure documentation requirements are met, restraints are applied correctly, and that the restrained patient's environment is free from potentially dangerous items. Dated 5/16/16.
5. Audit results are provided to the Chief Nursing Officer, along with any encountered issues, which are addressed immediately and required follow-up completed. Dated 5/16/16 and ongoing.
6. A report on unit-specific restraints and audit results is presented by the nursing leaders during the daily facility safety huddle/nursing huddle. Began reporting unit-specific restraints in 2015, and began reporting additional detail on audit results on 5/18/16 and ongoing.
7. Audit results will be reported through the facility Quality/Safety Committee beginning with the June 2016 meeting.

(2) Patient supervision/patient belongings
1. Education/key points were developed for nursing staff regarding the Patient Belongings and Search Policy, to include the following:
The patient inventory list is to be completed on all admissions to the inpatient units. Dated 5/16/16
Any items not sent home are to be inventoried and listed.
Any items (contraband, valuables, medicines, weapons, etc.) that are stored and/or confiscated by the hospital must be listed on the Patient Inventory List, labeled and signed by both a staff member and the patient.
Patients are to verify collection of all items and to sign the form on admission even if no items are collected
2. Nursing staff were educated on the Patient Belongings and Search policy key points by their unit leaders and during their unit safety huddles. Dated 5/16/16 and ongoing.
3. A decision was made to remove patient belongings from a patient's room if a patient is in restraints; or if a patient exhibits any mental status changes-such as confusion- whether or not the patient is in restraints. Dated 5/17/16.
4. An audit tool was developed for utilization by the nursing leaders/nursing units to track compliance with completion of the Patient Inventory List upon patient admission. The date on the action plan was 5/13/16.
5. The audit tool was initiated and completed on 100% of patients to ensure each patient's Patient Inventory List was completed. For any patient who did not have a belongings sheet in place the belongings inventory was immediately completed and filed on the patient's chart. Dated 5/13/16 and ongoing.
6. Audit results are provided to the Chief Nursing Officer, along with any encountered issues and required follow-up completed. Dated 5/13/16 and ongoing.
7. A report on patient belongings compliance is presented by the nursing leaders during daily facility safety huddle/nursing huddle. Dated 5/18/16 and ongoing.
8. Audit results will be reported through the facility Quality/Safety Committee beginning with the June 2016 meeting.

(3) Observations and Interviews
Observation on 5/17/16 at 7:40 AM at Building A, in the education dining room, revealed employee training for restraints, procedure for assessing and securing patient belongings, and the use of fire extinguishers was being provided for the facility employees.

Observation of a Staffing Huddle at Building A on 5/17/16 at 9:30 AM, on the CPU (cardiopulmonary unit), revealed the unit manager conducting a brief meeting with unit's staff regarding staffing and patient discharges. Further observation revealed the facility's restraint policy and patient belonging policy was reviewed and the staff were given the dates to attend the facility's mandatory training for restraints and patient belongings.

Observation on 5/18/16 at 8:00 AM at Building A, in the education dining room, revealed employee training for restraints, procedure for assessing and securing patient belongings, and the use of fire extinguishers was being provided for the facility employees.

Observation on 5/18/16 at 11:45 AM at Building A, in the Nursing Conference room, of a facility wide safety huddle in which all department managers attend, revealed the administrative staff discussed the mandatory employee training for restraints, patient belongings and fire extinguishers.

Observation on 5/18/16 at 12:00 PM at Building A, in the Nursing Conference Room, of a Nursing Clinical Huddle, conducted by the CNO, revealed all nursing unit mangers attend the daily meeting. Further observation revealed the policies regarding restraints and patient belongings were reviewed. Further observation revealed a quality management tool regarding the use of restraints for each unit was reviewed and discussed. Further observation revealed the unit managers are reviewing all patient medical records to ensure the patient belonging form is being filled out and all patient belongings are secured or noted in the medical record. Further observation revealed auditing tools for the use of a restraint and patient belongings were reviewed and these tools are completed by the managers, brought to the CNO, and then forwarded to the Quality Management.

Observation on 5/19/16 at 1:15 PM at Building B, in the dining room, revealed employee training for restraints, procedure for assessing and securing patient belongings, and the use of fire extinguishers was being provided for the facility employees.

Interview with the Risk Manager at Building C on 5/21/16 at 9:00 AM, in the conference room, revealed the facility had implemented the Metro mandatory training for employees regarding restraints, patient belongings and fire extinguishers.

Facility documentation revealed 96% of Building A employees had completed the training, 88.64% at Building B and 89.69% at Building C. Facility documentation revealed Building B and Building C had deployed the "Train the Trainer Model" and all departments have their trainers and a central education log sheet is on the shared drive. The log is updated daily and each manager is accountable to provide the hands on training to each team member prior to working any upcoming shift. Once the training had occurred the manager is accountable to update the education log and send sign in sheets to the Quality Department.

The action plan for the fire which occurred on 5/10/16 was presented 5/25/16 at 10:15 AM by the Director of Quality Management and the Metro Director of Quality Management, in the conference room. The facility implemented the action plan and the plan was reviewed and verified as described above. The immediacy was removed on 5/25/16.

Refer to Standard A395
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, review of facility documentation, medical record review, observation, and interview, the facility failed to supervise the nursing care provided for a patient who was in restraints for 1 patient (#1) of 4 patients reviewed for restraints.

The findings included:

Review of facility policy, Restraints, last review 9/6/13, revealed "...definitions [1] restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely..." Further review revealed "...monitoring and assessments shall occur at least every 2 hours and documented on all patients in restraints...alternatives: alternative to and less restrictive forms of restraints considered by the caregiver should be documented at least once per shift...[iv] other monitoring: other monitoring activities should be performed at least every 2 hours, or more frequently if indicated by the condition or behavior of the patient. During monitoring, the patient should be assessed for: signs of any injury associated with the use of restraint, nutrition and hydration needs...circulation, hygiene, and elimination...physical and psychological status and comfort..."

Review of facility policy, Patient Belongings and Search Policy #4264, last reviewed on 11/9/15, revealed "...it is the policy of [facility] to maintain written procedures for the inventory and storage of patient belongings and valuables...all staff from the point of presentation have the responsibility to inventory belongings, valuables and contraband...the patient inventory list form must be completed...contraband items will be handled in the following manner when brought to the unit: dangerous items such as weapons will be either sent home with the patient's family/friend/significant others or sent to security..."

Medical record review revealed Patient #1 was admitted the facility on 5/8/16 with diagnoses including Metabolic Acidosis (a condition that occurs when the body produces excessive acid in the body fluids), Alcoholism, History of [DIAGNOSES REDACTED] (a softening and weakening of the bones usually due to a Vitamin D deficiency), Chronic Pancreatitis, and Acute Kidney Injury. Further review revealed the patient had a past history of Dementia felt to be related to alcohol. Further review revealed the patient was transferred to another acute care facility on 5/11/16.

Medical record review of an Admission History and Physical dated 5/8/16 revealed "...history of chronic alcoholism...Previous records indicate a history of chronic pancreatitis and dementia related to alcohol..." Further review revealed "...in the Emergency Department, the patient was found to have a metabolic acidosis...awake and alert, mildly confused..." Further review revealed "...assessment and plan: (1) metabolic acidosis...(2) alcoholism...(5) history of chronic pancreatitis secondary to alcoholism...(6) history of dementia felt to be related to alcohol..."

Medical record review of an admission History assessment dated [DATE] at 3:29 PM revealed "...patient belongings: clothing, money, other annotate...disposition of belongings: with patient..." Further review revealed no patient belonging valuables checklist.

Medical record review of a Nurse's Note dated 5/9/16 at 7:51 AM revealed "...psychosocial: mood/affect: patient...anxious...behavior: apprehensive..."

Medical record review of a Nurse's Note dated 5/10/16 at 2:00 PM revealed "...pt. [patient] pulling out tubes...up in room walking in blood...dr. [doctor] called for restraints...neurological: LOC [level of consciousness], confused..." Further review revealed at 2:30 PM "...restraint initial, done...soft wrist...reason ordered: lines and tubes..." Further review revealed at 4:30 PM "...soft wrist restraint... RN assessment continued..."

Medical record review of an Emergency Department (ED) Physicians Consult Progress Note dated 5/10/16 at 7:00 PM revealed "...pt. is inpt [inpatient] victim of burns, he dropped his keys then lit a piece of paper on fire. Denies SI [suicidal ideations]...was in restraints by report..."

Medical record review of a Critical Care Note dated 5/10/16 at 7:00 PM revealed "...with metabolic [DIAGNOSES REDACTED] secondary to ETOH [alcohol] abuse lit a piece of paper on fire which then fell on to the bed. Now with 60% body surface burns..."

Medical record review of a Pulmonary Critical Care Medicine Consult note with no date or time revealed "...called emergently to evaluate pt. that burned himself on floor..." Further review revealed "...[1] severe 60% BSA [body surface area] third degree burns...volume resuscitation ongoing...transfer to [named burn center]... [2] acute respiratory failure after burns ? [questionable] inhalation injury....on ventilator..."

Review of an Investigation Summary Worksheet dated 5/10/16 revealed "...was subsequently admitted to a general medical floor with a diagnosis of [DIAGNOSES REDACTED][intravenous line for medication administration]. The physician was notified and the patient was placed in soft wrist restraints for line protection at 2:30 PM..." Further review revealed "...at approximately 5:38 PM, staff responded to the patient's call bell/request for assistance, and found his mattress and blanket on fire...." Further review revealed "...staff began to evacuate the involved patient to the Emergency Department...per the patient's self-report to the emergency room Nurse during the intake process, he had lit a piece of paper on fire in order to look for his keys, and the paper fell on to the bed, starting the fire..." Further review revealed "...the patient sustained 60% of BSA 3rd degree burns from this fire..."

Observation of the patient's bed involved in the fire on 5/11/16 at 3:32 PM, revealed major damage observed to the left side of the bed, and charred burns observed to the left side rail. Further observation revealed a soft wrist restraint still attached to lower frame of the right side of the bed and a soft wrist restraint hook to the left side of the bed. Further observation revealed water leaking from the mattress of the bed.

Interview with the Nurse Manager for the unit where the fire originated on 5/11/16 at 1:50 PM, in the conference room, revealed "... the patient was placed in soft wrist restraints on 5/10/16 around 2:15-2:30 PM due to pulling his IV [intravenous line used for medication administration] out..." Further interview revealed "...they found a lighter in the room and the lighter was removed from the room by the fire investigator, which was thought to have been the source of the fire..." Further interview revealed "...the patient suffered injuries to his face, Left arm, left chest..."

Interview with ED RN #1, who worked in the ED and was present when the patient arrived in the ED on 5/11/16 at 2:40 PM, in the ED conference room, revealed "...the patient was brought to the ED by the ICU [Intensive Care Unit] nurse and another male...the bed was charred and the mattress was burned...he had burns to the left shoulder, left anterior chest, his face and the hair to his left side of the head was singed..." Further interview revealed "...he had taken a piece of paper and lit the paper with a cigarette lighter to find his keys...he used a lighter to light the paper...his left arm was in a restraint which was melted from the fire..."

Interview with Certified Nurse Assistant (CNA) #1 on 5/11/16 at 4:05 PM, in the conference room, revealed the CNA was working on the medical surgical floor where the fire occurred on 5/10/16. Further interview revealed the CNA had been in the patient's room 5 minutes prior to the fire. Continued interview revealed "...he was wearing restraints to both hands...he had pulled his IV's out prior...the restraints were just loosely applied to his hand...he was confused and wanted me to give him a knife to cut the restraints off to go to the store..." Further interview revealed "...he hollered at us all when we would go by the room wanting us to come in his room and cut the restraints off...the last time I seen him in the room he was confused..."

Interview with RN #1 on 5/11/16 at 4:15 PM, in the conference room, revealed the nurse was the patient's primary nurse and the day shift charge nurse on the unit where the fire occurred. Further interview revealed "...the patient was confused and we had put soft wrist restraints on him earlier in the afternoon because he was trying to get of the bed and pulling his IV's out..." Continued interview revealed "...he had a lighter in the room...I talked with the patient prior to the fire and told him because he was pulling his IV's out that we had to put the restraints on him...he was confused and not intact...he was just not right when you talked to him..." Further interview revealed "...the wrist restraints were applied loosely just to keep him from pulling his IV's out..." Further interview revealed "...we were in the medication room and the fire alarm went off...I heard someone scream for help and when I walked out of the medication room I saw smoke in the hallway...[named CNA] was in the room with the patient trying to put the fire out..."

Interview with the Chief Nursing Officer (CNO) on 5/12/16 at 10:20 AM, in the conference room, revealed "...I am concerned about the restraints being applied loosely for the patient...if the patient needed restraints from pulling IV lines out then they should not be applied loosely..." Further interview revealed "...I think I would have taken the lighter from the patient initially but definitely when the patient had signs of confusion..."

Interview with the facility's Risk Manager (RM) on 5/18/16 at 1:30 PM, in the conference room, revealed "...the patient had been placed in soft wrist restraints around 2:30 PM on 5/10/16...he was admitted with metabolic acidosis, alcohol related dementia and had [DIAGNOSES REDACTED] related to the alcohol..." Further interview revealed "...he did have a history of dementia...for any patient who had dementia the restraint should have not been applied loosely, they should be applied correctly..." Further interview confirmed there was lack of supervision related to not removing the lighter once the patient was confused and placed in restraints, and the physical restraint was not applied correctly.
VIOLATION: FIRE CONTROL PLANS Tag No: A0714
Based on review of facility policy, interview, and observation, the facility failed to ensure employees were trained in the safe operation and deployment of a fire extinguisher for 4 of 5 employees who were directly involved in a fire.

The findings included:

Review of facility policy "Fire and Emergency Plan-Code Red" last revised 8/29/13 revealed "...all employees can access a description of their responsibilities in the event of fire..." Further review revealed "...list of accountability: all associates...procedures: extinguish: when using fire extinguisher, follow these steps: PASS...pull ring and stand 6-8 feet away...AIM at the base of the fire...Squeeze the handles together to dispense chemical...Sweep the extinguisher from side to side..."

Interview with Certified Nursing Assistant (CNA) #1 on 5/11/16 at 4:05 PM, in the conference room, revealed "...the fire alarm went off but they had been doing some fire alarm testing...I saw smoke when I rounded the corner and when I stepped into his room (Patient #1) the bed was on fire...I ran in the room and folded some sheets that were in the room and started beating the sheets that were on fire...I was trying to put the fire out...someone got the fire extinguisher...I had never pulled the pin on an extinguisher...the sprinkler system went off at that same time...the sprinkler put the fire out..."

Interview with Registered Nurse (RN) #1 on 5/11/16 at 4:15 PM, in the conference room, revealed "...when I got down to the room there were flames...I screamed for help...we got the fire extinguisher and it was handed to [named RN]...I think she activated it but I am not sure...I had never used a fire extinguisher before so I was not real sure how to activate it..."

Telephone interview with RN #3 on 5/11/16 at 4:45 PM revealed "...we grabbed the fire extinguisher from the supply room...[named RN] handed it to [another RN] and then they gave it to me...I think I pulled the pin and aimed it at the fire, but I cannot remember if it went off or not...I had never used one before..."

Telephone interview with RN #4 on 5/11/16 at 5:00 PM revealed "...I came from another floor...when I got over there I saw heavy smoke...I ran into the room...the patient was engulfed in flames...we grabbed the fire extinguisher but I am not sure if it was deployed or not...we heard a sound and the sprinkler system went off...I had never used a fire extinguisher before..."

Interview with the Chief Nursing Officer (CNO) on 5/11/16 at 5:15 PM, in the conference room, revealed "...what I hear from the interviews is the staff need training regarding how to operate the fire extinguishers...all of them said they were not familiar with the deployment of the fire extinguisher..." Further interview revealed "...we have never trained the staff with using an actual fire extinguisher..."

Observation and interview on 5/12/16 at 10:45 AM on the unit where the fire occurred revealed a fire extinguisher in the trash can. Further observation revealed the fire extinguisher pin was pulled; the indicator mark was pointed toward the green area which indicated the fire extinguisher had not been deployed during the fire. Interview with the Plant Operations supervisor confirmed the extinguisher had not deployed.