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Based on document reviews, conducted on 5/24/10 and 5/25/10, the surveyor determined that the surgical staff did not utilize the surgical alcohol prep ( Chlora Prep) correctly during the surgical procedure on patient MR #1 on 5/17/10. A review of the Chlora Prep manufacturer's literature revealed that the manufacturer clearly stated that for patients with hair near the surgical site, the alcohol prep must be left to dry for up to an hour before the surgery can begin, due to fire potential. And a review of this patient's medical record revealed that the drying elapsed time was only between 5-7 minutes.

Based on interview and document reviews, conducted on 5/24/10 and 5/25/10, the surveyor determined that the facility has not been providing unit/department specific fire safety/evacuation training to the hospital staff. A review of the training documents for the past year revealed that the topics taught in every training are the same, with no consideration of unit/department potential fire hazards, such as OR fires. An interview with the director of security confirmed same. And based on interviews on 5/24/10 and 5/25/10, the surveyor determined that the fire safety training provided to the OR staff was ineffective. Interviews with all,except one, of the OR staff connected with this surgical procedure of 5/17/10 revealed that the staff did not activate the fire alarm after the OR fire, left the patient in this OR for at least an hour, and stored the burned surgical items, such as drapes, masks,etc. in a bag in a locked office nearby. The fire alarm should have been activated, the patient should not have been left in the OR and the burned items should not be stored anywhere in the hospital building. ( LSC 2000 edition- section 19.7)

Based on record review, review of policy and interview, it was determined that the facility did not develop and implement a policy and procedure to ensure the safety of the patient during a surgical fire. (#1)

Based on record review, review of manufacturers recommendations, and interview, it was evident that the surgical staff failed to conform to current standards of practice in the safe application of a cleansing agent. (#1)

Based on record review, it was evident that the facility did not provide training for the use of a cleansing agent that did not correspond to manufacturers recommendations. (#1)

Findings include:

Review of medical record #1 on 5/24/10 found that the patient's hair went on fire during a surgical procedure in the OR.

At interview with the attending surgeon 5/24/10 and the resident 5/25/10, it was stated that the immediate action included removing the oxygen mask as well as the drapes from the patient's face and throwing it to the floor of the OR.

It was stated by the circulating nurse that smoke was coming from that mask at the time of removal. Neither physician stated that they ensured that the oxygen source was turned off when they removed this mask. They stated that they were not aware if it was on or off but that their action was immediate. This was corroborated by interviews with all present nursing staff, including the scrub tech , the RN.

Review of facility policy and procedure on 5/25/10, ( Clinical 6.3 ), titled " Fire Protocol and Responding to Surgical Fires " does not note that oxygen must be turned off prior to the removal of any face mask to prevent the fire from being further fueled. It states that staff should immediately remove all burning objects from the patient.

The surgical staff failed to allow the patient's hair to dry after the application of a cleansing preparatory agent prior to the use of a bovie cautery.

Review of MR#1 on 5/24/10 found that the patient's hair went on fire during the course of a surgical procedure in the OR.

At interview with the the surgical resident on 5/25/10 found that she applied the chloraprep (2% ) to the operative site and waited for 5 to 7 minutes prior to the attending surgeon utilizing the cautery. The surgery commenced at 1604 and the flames occurred at 1607 hours. The time of the prep application is not noted in the medical record.

Review of the training provided by the facility for the use of the chloraprep (2%) did not correspond to the manufacturer's recommendations.

The inservice training provided by the facility notes that 3 to 5 minutes is the recommended time for waiting for the area to dry. It does not note that use on skin with hair requires a more protracted period of time to dry.

In this case, the area of surgery was the scalp, where a small area was clipped and the surrounding area was scalp hair.

The area clipped by the the surgical staff was 1/ 1/3 inches in diameter as noted in the medical record. .

Review of the manufacturer's recommendations finds it is stated that patients whose surgical site contains hair requires up to one (1) hour to dry. Specifically, it is stated " do not drape or use ignition source ( e.g. cautery , laser ) until solution is completely dry ( minimum of 3 minutes on hairless skin,; up to 1 hour in hair ).