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.

Based on document review and staff interviews it was determined the hospital failed to ensure the House Supervisor followed the hospital's Incident Reporting policy. This failure has the potential to negatively impact patients receiving care at this hospital.

Findings include:

1. A review of the hospital policy titled Tobacco and Smoke Free Campus Policy, last revised 7/18, states: "This policy has been implemented to establish procedures to ensure the right to a smoke-free campus experience for employees, patients and visitors of Highland Hospital." The policy further states under the heading of definitions: "Electronic Cigarette (also known as e-cigarettes and personal vaporizers)." Under the heading titled Policy Defined states in part: ".... Smoking by employees is prohibited on campus."

2. A review of the hospital document titled Security America, Inc. Incident Report reveals on 5/12/19 at 4:16 a.m. fire alarm panel activation took place. Detailed description of incident: "At approximately 0416 hours fire alarm panel activated indicating smoke 1st floor lounge, this is the HHC Detox TV Room, this officer (Security Guard #1) responded to site, this officer and HHC staff members Registered Nurse (RN) #1 and Behavioral Health Technician (BHT) #3 conducted complete sweep of unit, no discrepancies noted .... Charleston Fire Department Unit 456 arrived on site, fire response terminated."

3. A review of the hospital document titled Security America, Inc. Incident Report reveals on 5/24/19 at 12:34 a.m. fire alarm panel activation took place. Detailed description of incident: "At approximately 0034 hours fire alarm activated indicating smoke 2nd floor, this officer (Security Guard #1) responded on site to inspect. Complete sweep of Children's and Tween units by this officer and staff members, no discrepancies noted on Children's unit. This officer and House Supervisor #2 smelled a strong sweet smell emanating from North nurse's station during sweep of Tween unit .... RN #1 was assigned to detox unit on 12 May 2019 when fire alarms were activated at 0416 hours. After reviewing camera footage of both fire alarms incidents, evidentiary visuals exist of staff member RN #1 handling vaping apparatus prior to both fire alarm incidents. This officer passed this information onto Nursing Supervisor #2 for investigative inquiry... This officer spoke to fire department unit 456 personnel about situation ..."

4. A review of the job description for Nurse Supervisor states in part: "...Assures any suspect Adverse Drug Reaction, Infection Control or Incident Report are completed thoroughly and accurately, at the time of the occurrence. Assures that the follow-up necessary is completed and documented per policy/procedure."

5. A review of the hospital policy titled Incident Reporting, last reviewed 7/28/18, states: "All reports need to be completed immediately and given to the Nurse Supervisor's office for triage. The report should be filled out completely with accurate time, date, witnesses and other relevant facts."

6. In a telephone interview with House Supervisor #1 on 6/25/19 at approximately 10:55 a.m. it was revealed that he was working during the incident on 5/24/19 when the fire alarm went off. He said security does the incident report but he never received a copy of the report. He did not call the Administrator on call that night. He stated, "I told the Assistant Director of Nursing (ADON) the next morning in report." When questioned why he did not notify the Administrator on call he stated, "It wasn't an actual fire so I didn't bother them."

7. An interview was conducted on 6/25/19 at approximately 1:00 p.m. with the Administrator on call for the day of 5/24/19. During the interview he stated he was never notified of a fire alarm being activated and the fire department responding during his time on call. He stated, "That would be something I would be expected to be notified of if the fire department responded to the hospital."

8. An interview was conducted with the Director of Quality and Risk Management on 6/25/19 at approximately 9:00 a.m. She stated she was not made aware of the incident until the Director of Security brought her the incident report for 5/12/19 and 5/24/19 and notified her of the situation. She stated, "I sent out an email telling them I had received no incident reports related to either date and wanting to know if notification had been made to nursing, her manager or Human Resources (HR). The only thing I received back was that it was being investigated. I have had no further follow-up on the situation." When asked if the fire department responding to the fire alarm would warrant a notification to the Administrator on call she stated, "I would think so and an incident report being filled out and turned in to me."