HospitalInspections.org

Based on observations, record review and interviews it was determined the Hospital failed to ensure that on 6/17/14 a housekeeper, a mental health worker and a secretary followed fire and safety procedures during an actual fire. Subsequent to this incident the facility failed to ensure that all staff working on the 5 Metro Boston Mental Health Units (MBMHU) were appropriately trained and familiar in all procedures related to fire safety in accordance with Chapter 19 of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2000 Edition Sections: (A): 19.7.2. Procedures in case of a fire; and, (B) 19.7.1.1 Evacuation and relocation plan and fire drills

A) 19.7.2. Procedures in case of a fire;

Section 19.7.2.1 states for health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy ' s fire safety plan.

NOTE: Section 19.7.2.1 is also known as Rescue, Alarm, Contain, Evacuate (RACE).
Section 19.7.2.2 states a written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

Section 19.7.2.3 states all health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

THE FINDINGS INCLUDE:

The Hospital's Life Safety Management Plan and the Emergency Code Red (notification of a fire) Response indicated that upon the identification of a fire/smoke emergency the staff will follow the acronym R.A.C.E.; R indicating rescue any patients/staff; A indicating alarm, activate the nearest fire alarm pull station; C indicating contain, close all doors and windows; and E indicating evacuate/extinguish.

However, a Hospital Incident Report, dated, 6/17/14, indicated a patient (Patient #1) on the 9 N MBMHU informed a staff housekeeper that there was a fire in the women's bathroom. The housekeeper yelled; another staff person grabbed the fire extinguisher and put out the fire and another staff member called the Code Red. The Massachusetts Department of Public Health Police Officers arrived to the Code Red on and upon their arrival, activated the fire alarm system.

Surveyors interviewed Housekeeper #1 at 11:30 A.M. on 6/25/14 with her supervisor present. Housekeeper #1's primary spoken language was not English. Housekeeper #1 said Patient #1 came out of the women's bathroom and reported there was a fire in the bathroom. Housekeeper #1 said she yelled help me, help me and ran up and down the halls. Housekeeper #1 said there was black smoke. Housekeeper #1 said she had no key for the fire alarm pull station.

Surveyors interviewed Mental Health Worker #1 at 2:00 P.M. on 6/25/14. Mental Health Worker #1 said he heard Housekeeper #1 yelling and thought she might have been attacked by the way she was yelling. Mental Health Worker #1 said he ran to Housekeeper #1 and saw her pointing to the women's bathroom saying fire. Mental Health Worker #1 said he saw the fire, ran for the fire extinguisher and called out to the secretary to call a code red, which she did.

Housekeeper #1, Mental Health Worker #1 and the floor secretary failed to follow the second step of R.A.C.E.which was to activate the Hospital's fire alarm system and contain the fire by closing the door to the women's bathroom. It was not until the campus police arrived on the unit subsequent to the code red being called was the fire alarm pull station activated. Hence there was a delay in the containment of the fire and notice to the city's fire department.

Therefore, facility personnel did not activate the building fire alarm using the nearest manual fire alarm box and then execute immediately their duties as outlined in the fire safety plan in accordance with Section 19.7.2.

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B) Evacuation and relocation plan and fire drills:

Section 19.7.1.1 states the administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.
Section 19.7.1.3 states employees of health care occupancies shall be instructed in life safety procedures and devices.

19.7.1.3 states employees of health care occupancies shall be instructed in life safety procedures and devices.

THE FINDINGS INCLUDE:

ACTIVATION OF PULL STATIONS:

The facility's pull station devices located on each of the Mental Health units are secured and require a key for operation. The following items were identified upon interview of staff members regarding the staff's knowledge of the life safety devices (pull stations).

1. Surveyors toured the 9 North MBMHU at approximately 8:00 A.M. on 6/25/14 and made observations and interviewed 3 Mental Health Workers (#2, #3 and #4) and 1 nurse (#1) and House Keeper #2. Mental Health Worker #2 and #3 said they have no keys to open the locked fire pull station on the unit. Nurse #1 was observed fitting his key into the locked fire alarm pull station and said the key did not fit. Housekeeper #2 said he did not have keys to the fire alarm pull station or the locked fire extinguisher. Housekeeper #2 said if he identified a fire, he would follow the lead of a mental health worker.

2. Surveyors toured the 10 North MBMHU at approximately 9:00 A.M. on 6/25/14 and interviewed Nurse #3 and Mental Health Worker #5 and #6. Nurse #3 and Mental Health Worker #5 said they did not have keys to the fire pull station. Mental Health Worker #6 said he had a key, but when he tried to open the locked fire pull station the key did not fit the lock.

3. Surveyors toured the 10 South MBMHU at approximately 9:25 A.M. on 6/25/14 and interviewed Housekeeper #3. Housekeeper #3 said she did not have a key to the fire alarm pull station.

4. Surveyors toured the 8 South MBMHU at approximately 9:50 A.M and interviewed Nurse #4. Nurse #4 showed the Surveyors her keys. Nurse #4 had a key for the fire extinguisher and the fire pull station, but Nurse #4 was unsure of the function of each of the two keys.

5. Surveyors toured the 4 South MBMHU at approximately 10:15 A.M. Observations and interviews were conducted of Nurse #5 and Housekeeper #4. Nurse #5 said he placed the key for the fire pull station into the lock, but it did not open the lock fire pull station. Housekeeper #4 said she had no keys to unlock the fire extinguisher and unlock the fire alarm pull station.

6. Surveyors interviewed Housekeeper #1 at 11:30 A.M. on 6/25/14 with her supervisor present. Housekeeper #1's primary spoken language was not English. Housekeeper #1 said she had no key for the fire alarm pull station.

R.A.C.E. PROCEDURES:

During the morning hours of 6/25/14 at approximately 9:00 A.M. while reviewing records, it was observed that the facility has a "Fire Procedure Plan" which incorporates "RACE" (Rescue, Alarm, Contain, Evacuate) procedure into the plan. A total of four (4) staff members (house keepers) were asked various questions pertaining to the fire safety procedures (RACE) designed for the hospital. The following information was obtained from each of the four staff members:

1. At approximately 2:05 P.M. Housekeeper #1 of the 9-North unit was interviewed. Housekeeper #1 was the initial hospital employee to discover the actual fire on 6/17/14 in the women's bathroom of the 9-North unit. House keeper #1 was asked various questions pertaining to "RACE". This housekeeper was not aware of all the components of the policy. The only information provided from Housekeeper #1 is that the patients would be removed from the room in the event of fire. When asked if the door to the bathroom was initially closed after discovering the fire, the answer was no. Housekeeper #1 was not aware of containing the fire, instead she ran down the corridor yelling help, help. When asked if she could activate the alarm system, Housekeeper #4 stated she could not do that and would seek help from a mental health worker. Housekeeper #4 does not have a key (B-key) to unlock the pull station devices for alarm activation. Housekeeper #4 does not have a key (FH) to unlock the fire extinguisher cabinets.

2. At approximately 9:25 A.M. Housekeeper #3 on the 10-South unit was asked various questions pertaining to "RACE". This housekeeper was not aware of all the components of the policy. The only information provided from Housekeeper #3 is that the patients would be removed from the room in the event of fire and the door would be closed. When asked if she could activate the alarm system, Housekeeper #3 stated she would seek help from a mental health worker. Housekeeper #3 does not have a key (B-key) to unlock the pull station devices for alarm activation. Housekeeper #3 does not have a key (FH) to unlock the fire extinguisher cabinets.

3. At approximately 9:50 A.M. Housekeeper #4 on the 4-South unit was asked various questions pertaining to "RACE". This housekeeper was not aware of all the components of the policy. The only information provided from Housekeeper #4 is that the patients would be removed from the room in the event of fire and the door would be closed. When asked if she could activate the alarm system, Housekeeper #4 stated she would seek help from a mental health worker. Housekeeper #4 does not have a key (B-key) to unlock the pull station devices for alarm activation. Housekeeper #4 does not have a key (FH) to unlock the fire extinguisher cabinets.

4. At approximately 8:10 A.M. Housekeeper #2 on the 9-North unit was asked various questions pertaining to "RACE". This housekeeper was not aware of all the components of the policy. The only information provided from Housekeeper #2 is that the patients would be removed from the room in the event of fire. When asked if he could activate the alarm system, Housekeeper #2 stated he would seek help from a mental health worker. Housekeeper #2 does not have a key (B-key) to unlock the pull station devices for alarm activation. Housekeeper #2 does not have a key (FH) to unlock the fire extinguisher cabinets.


TRAINING:

A total of four (4) personnel files were reviewed for the initial & annual training of the Fire Procedure Manual to ensure all components are being incorporated for all personnel. The four files reviewed were all of Mental Health Employees which work on the mental health floors containing secured units and secured alarm systems. The following information was observed during the record review:

At approximately 3:15 P.M. while reviewing personnel records of Mental Health worker #1; Mental Health worker #2; Nurse #1 and Nurse #2; it was observed that annual training does not incorporate proper information. The pull station devices located on each of the Mental Health units are secured and require a key for operation. Of the four records reviewed, only Mental Health worker #1 and #2 were initially trained on the key operation of the alarm system. There is no documentation for Nurse #1 and #2 that this training has occurred. Each of the four records reviewed did have an annual in-service form which covered fire safety procedures. However, after closer review of the annual training material, it was observed that the training packet does not state that a key is necessary to activate the alarm system. The training states to simply activate the nearest alarm to the person discovering the fire, with no mention of having a B-key for this operation.

As a result of document review and staff interview, it is evident that the proper training of the fire safety procedures is not performed as required. All staff is not trained on the use of and response to fire alarms. All staff is not trained and instructed in life safety procedures & devices. All staff is not informed of the procedures with respect to their duties under the plan.