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Based on observation, interview, policy review and review of provisions of Life Safety Code (standards dealing with the hazards to human life in buildings), the facility did not meet the provisions of the National Fire Protection Association and failed to ensure that the facility provided a safe environment for all patients and staff. The facility was responsible for the safety and treatment of patients receiving long term acute care services. The systemic failure resulted in the facility being out of compliance with 42 CFR 482.41 - Condition of Participation: Physical Environment. The facility census was 30.

Refer to A-0710 for findings.

Based on observation, interview, policy review, and review of the Life Safety Code (standards dealing with the hazards to human life in buildings), the facility did not meet provisions of the National Fire Protection Association and failed to provide a safe environment when they:
- Utilized portable space heaters in four patient (#1, #4, #9 and #10) rooms of 30 patient rooms observed and at the 200 hallway nurses' station.
- Utilized portable space heaters that exceeded the maximum acceptable heating element (part of an electrical device that converts electricity into heat) temperature of 212 degrees.
- Did not educate staff how to use the portable space heaters; and
- Did not monitor patient rooms for the potential for fire while portable space heaters were in use.
This had the potential to place all patients and staff at risk for injury by fire. The facility census was 30.

Findings included:

1. Record review of Life Safety Code, National Fire Protection Agency (NFPA) 101, section 19.7.8, showed that portable space-heating devices were prohibited in all health care occupancies except when used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).

2. Record review of the facility's policy titled, "Electrical Safety" revised 11/12, showed that in the event of the necessity for use of portable heaters, only electric ceramic heaters are permitted following inspection and approval.

3. Observation on 12/17/13 at 10:00 AM showed the following:
- A portable space heater in Patient #1's room. The space heater was in use while oxygen (gas which increases the risk of fire) was in use, which further increased the risk of fire. The patient's door was closed and there were no staff directly monitoring the room.
- A portable space heater in Patient #4's room. The space heater was in use, sitting approximately one and one-half feet behind a chair and dresser. A sling (thick cloth used to transfer patients from bed to chair) was draped over the chair, which further increased the risk of fire. The patient's door was closed and there were no staff directly monitoring the room.
- A portable space heater in Patient #9's room. The space heater was in use, on the floor at the foot of the patient's bed, while the patient's door was closed and there were no staff directly monitoring the room.
- A portable space heater in Patient #10's room. The space heater was in use, balanced on a chair at the foot of the patient's bed, while the patient's door was closed and there were no staff directly monitoring the room.
- A portable space heater in the 200 hallway nurses' station. The space heater was in use and placed next to combustible (easy to catch fire) material.

4. During an interview on 12/17/13 at 10:25 AM, Patient #1 stated that she had been at the facility since her admission on 12/14/13 and complained that her room was very cold, so the staff placed a portable space heater in her room a "couple of days" ago.

5. During an interview on 12/17/13 at 3:10 PM, Patient #4, who was paralyzed and confined to a bed or wheelchair, stated that staff placed a portable space heater in his room a few days ago, because the room was cold and because the staff reported they were having problems with the building's heater.

6. Observation on 12/17/13 at 10:35 AM showed Staff G, Plant Manager (oversees the structural function of the facility), tested the temperature of the heating element of the portable space heaters with a heat thermometer. The heating element temperature was 225 degrees Fahrenheit.

7. During a telephone interview on 12/18/13 at 4:00 PM, Technical Support staff from the portable space heater manufacturer stated that the heating element of the portable space heater can reach 350 degrees Fahrenheit, and was not intended for use in hospitals.

8. During an interview on 12/17/13 at 10:40 AM, Staff G stated that the portable space heaters were brought into the facility on 12/14/13 because the facility had problems with the heater on the 200 hallway, and because some of the patients complained they were cold. Staff G stated that on 12/14/13, he instructed the Charge Nurse to move patients who were cold to warmer patient rooms that were available, and to use the space heaters in the remaining patient rooms that were cold. Staff G stated that he did not educate the Charge Nurse on how to properly use or monitor the space heaters, that the Charge Nurse did not move patients to available rooms as instructed and placed the space heaters in the patient rooms instead. Staff G stated that he was informed on 12/13/13 by Staff A, Chief Executive Officer (CEO), to purchase the portable space heaters if needed. Staff G added that he was unaware that portable space heaters were prohibited in patient rooms and did not realize the facility policy regarding portable space heaters was incorrect.

9. During an interview on 12/17/13 at 3:30 PM, Staff A stated that:
- She approved the portable space heaters to be purchased and used if the facility needed them.
- She was unaware the heaters were in use until State Surveyors questioned staff about them.
- The heaters had been in use since 12/14/2013 around midnight.
- She was unaware portable space heaters were prohibited in patient rooms.
- She was unaware the facility policy to use portable space heaters was incorrect.

10. During an interview on 12/17/2013 at 3:15 PM, Staff C, Director of Nursing (DON), stated that:
- She was not aware portable space heaters were in use in patient rooms until the State Surveyors questioned staff about them.
- She confirmed that nursing staff were not instructed how to properly use the heater or to monitor the patients while the space heaters were in use.
- There were four available rooms that patients could have been moved to, to avoid the use of the portable heaters.
- She confirmed that the charge nurse did not transfer the patients who were cold to warmer, available patient rooms as requested by Staff G, because patients were warm once the space heaters were placed in the patient rooms.
- She was not aware that the heaters were prohibited in patient rooms.
- She was unaware the facility policy to use portable space heaters was incorrect.