HospitalInspections.org

Based on interview, record review and review of facility policies and procedures the facility failed to ensure that staff followed the facility tobacco policy for patients.
Failure to follow the facility tobacco policy placed patients in the facility at risk for serious injury and death from the risk of a fire in the facility.

Findings include:

1. The facility policy entitled " Tobacco Policy " revised 4/29/2013 read in part under
" III. Policy: C. Storage of Tobacco Products: Mailbox type containers (lockers) and automatic lighters are available for patient use " .
" D. Lighters: Patients will not purchase lighters. Automatic lighters will be installed on campus " .
" E. Wands for Metal Detection: Wands detecting metal, even in body cavities, have been purchased. Security staff will train Center for Adult Services staff on the use of wands " .
" IV. Procedure: " A. Ensure patients do not have tobacco products or lighting instruments on the ward or in buildings or outside the buildings in restricted areas " .
2. On 11/30/2016 at 8:20 PM, smoke was observed coming from Patient #1 ' s room. Staff called 911 and evacuated patients from the unit as well as 5 other units until the fire department declared the facility was safe for patients to return.
The patient admitted to starting the fire in their wardrobe closet with tissues but per the facility investigation " it was unclear if a cigarette lighter or some other form of ignition, such as a book of matches to start the fire in their wardrobe closet. "
3. On 1/10/2017 at 9:30 AM Staff #1, a registered nurse (RN) was interviewed. Staff #1 stated patient ' s with smoking privileges ' stored their smoking materials and lighters/matches in their smoking boxes for which the patients have their own key. Upon return to the unit staff used a wand to detect for lighters. Staff #1 stated they had not received any formal training on the proper way to use the wand. Staff #1 had been trained by another co-worker when they began work but no training since they were hired.
4. On 1/10/2017 at 9:50 AM Staff #2 an RN stated patients stored their smoking supplies and lighting materials in their smoking boxes for which patients had their own keys. Upon return to the unit staff would use the wand to check the patient for lighters. Staff #2 stated they were shown how to use the wand by their co-workers when they began working at the facility. Staff #2 had not received formal training on the procedure from the facility.
5. On 1/10/2017 at 10:10 AM Staff #3 a supervising RN confirmed the above information.

Cross- Reference with the State Fire Marshall tag K-741