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Based on , record review and interview the facility failed to ensure staff evaluate the safety needs of patients by adhering to the facility's fire responsibility protocol # EC.5.10.4.b dated 4/2011 . This failed practice resulted in adverse patient event. Citing all 24 patients on Unit 2.

Findings:

Review of complaint narrative TX 00156147 revealed information that on 12/13/11 a visitor smelled smoke on unit two (2) and informed two unit staff of the incident. The complainant documented staff did not do a thorough search and there was a fire in a patient's room resulting in a patient sustaining burns and other patients inhaled smoke.

During an interview on 3/21/11 at 9:40 am at the facility with Staff # 50 Registered Nurse she stated a visitor told her there was the smell of smoke and that it was coming from room # 2305. according to the Staff she did look into the room and two other patient's rooms and although she smelled smoke she did not see anything. The staff stated she did not report the smell of smoke or the visitor's concern to the other staff on the unit and she did not sound the fire alarm.


She went to the Lunch room on break for a few minutes when she heard the alarm of fire. The fire was in room 2305.

During an interview with Staff # 51 Patient Care Technician she stated the visitor told her that there was a smell of smoke, according to the Staff she smelt smoke checked the stairwell and patient rooms in the area she was working but did not see any smoke. According to the Staff she thought the smoke might have come form some visitors clothing who were near the stairwell. According to Staff # 51 she reported the information to the Nurse but she did not activate the fire alarm.

During the interviews they staff stated they did not activate the fire alarm because they did not see fire or smoke.

Review of the facility's Fire Policy # EC.5.10.4.b dated 4/2011 gave the following information:

" In order to assure the safety of patients, visitors, and staff, a standard response to fire, or to the potential of fire, defined plans are required. This fire plan describes the standard response for all staff within the hospital to an activation of the Fire Alarm or to conditions that indicate the presence of a fire in the area."

The staff on the unit were informed of the potential for a fire and they failed to activate the fire alarm system per protocol.

Based on record review, and interview, the facility failed to develop a patient plan of care that instructs patient on safety precautions while on oxygen therapy. This failed practice had the potential to adversely affect all patients on the unit receiving oxygen therapy. Citing three of three patients receiving oxygen therapy, patient 3s (1, 2 and 3).

Findings:

Review of Physician ' s history and physical dated 12/10/11 for Patient # 1 revealed the 71 year old patient was admitted to the hospital on 12/10/11 with admitting diagnosis of Chronic Obstructive Pulmonary Disease (COPD). There was documentation that her mental status was evaluated as being alert and oriented times three (person, time, and place). The patient was bed bound.
Review of nurses ' notes dated 12/12/11 revealed the patient was placed on oxygen therapy via nasal canulae. There was no documentation that the danger of smoking or using fire apparatus while on oxygen was discussed with the patient/family.

Review of nurses notes dated 12/13/11 documented the patient tried to light a cigarette while in bed with her oxygen canulae in place, the action resulted in a flash fire which burned her face.

Patient # 2
Review of physician ' s History and Physical dated 11/29/11 revealed the 73 year old patient was admitted to the hospital on 11/28/11 intubated and on a vent due to respiratory failure.
Review of nurses ' notes revealed the patient was taken off the ventilator on 12/4/11 and placed on oxygen via nasal canula. The patient was on oxygen therapy until 1/2/12.
There was no documentation that the danger of smoking or using fire apparatus while on oxygen was discussed with the patient/family.




Patient # 3

Review of physician ' s History and Physical dated 11/29/11 revealed the 72 year old patient was admitted to the hospital on 12/12/11 with dyspnea and increasing shortness of breath. The patient also had Chonic Obstructive Pulmonary Disease and was on oxygen at home via nasal canula. The patient had history of smoking in the past.

Review of nurses ' notes dated 12/12/11 revealed the patient was placed on oxygen via nasal canula until discharge on 12/14/11. There was no documentation that the danger of smoking or using fire apparatus while on oxygen was discussed with the patient/family.

Review of the facility ' s safety plan revealed no information that smoking or using flame while oxygen is in use could spark a fire.

During an interview on 3/21/12 at 10:35 am with facility ' s Nurse Administrative staff they stated there was no policy that addresses fire hazard while using oxygen in patients ' rooms.

Review of the facility ' s Smoking policy # EC.02.01.03 dated 2/2011 revealed information that patient would be informed of the facility ' s no smoking policy, review of the information given to patient ' s on admission only inform patients of the health risks of smoking.