HospitalInspections.org

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that Mercy Fitzgerald Hospital failed to ensure the protection and promotion of the rights of patients by failing to provide care in a safe setting (0144).

Cross reference with:
482.13(c)(2) Patient Rights: The patient has the right to receive care in a safe setting.

Based on a review of facility documents and staff interview (EMP), it was determined that Mercy Fitzgerald Hospital failed to maintain a safe environment for patients by failing to supervise a patient as per physician order, resulting in the patient starting a fire in the Emergency Department.

Findings include:
A review of facility policy Close Observation for Non-Suicide, Non-302, and Non-Alcohol/Drug Intoxication with Aggressive Behavior Patients: MCMC revealed, "Policy: A safety observer will be in place if there is a risk for patient injury and all other alternatives have been trialed, evaluated, and found to be ineffective using the Safety Observer Decision Algorithm. Procedure: ... 6. Staffing Office/Nursing Supervisor must be notified that a safety observer is being utilized. Nursing Responsibilities: ... 2. The nurse is responsible for assessment, development, and evaluation of the plan of care for patients requiring a safety observer and delegating responsibilities to the appropriate staff. ... 5. The Primary Care Nurse will attempt the following alternative strategies with the patient prior to requesting a safety observer be generated: ... a) For patients at risk for falls or elopement or for confused patients: ... iv. Visual Observation at 15 minute intervals. Safety Observer Responsibilities: ... 5. Safety observers may not leave their assignment until their replacement arrives. ... 7. It is the expectation that the safety observer give their full attention to the patient at all times. 8. The safety observer must be able to see the patient at all times. If a patient must go to the bathroom, the safety observer is to stand outside of the bathroom door while the door remains open three to four fingers widths. This is for the patient's own protection. ... 10. The safety observer must document on the Close Observation Form ... 12. The safety observer should always be within an arm's length of the patient. Ongoing Assessment: ... 4. Documentation: The following will be documented in the Electronic Medical Record (EMR): a) Use of the algorithm. b) Alternative interventions attempted c) Evaluation of alternative interventions d) Primary nurse verification e) Approval from manager/nursing supervisor f) Patient/family education and verbalization of their understanding of their education. 5. Safety observer completes documentation on the Close Observation Form every 15 minutes. ... ."

MR1 revealed the following Physician Orders related to observation level of the patient:
Continuous observation: Ordered by: EMP7. Ordered for: EMP7. Status: Done by: EMP8 - Tue Nov 30, 2021 01:14.

MR1 revealed NURSING PROCEDURE: NURSE NOTES: ... "Tech asked for pt to be on close obs b/c pt was attempting to leave. " (Tue Nov 30, 2021 00:00 EMP8)
NURSES NOTES: (Tue Nov 30, 2021 02:15 EMP8) "pt was escorted to restroom near Room 12. Patient was in bathroom for extended period of time. Nurses checked on patient several times. Ambulance brought in another patient. While nurses attending to ambulance, patient came out of bathroom went into Room 14 and removed another patient's hoodie and winter coat. Noted by nurse to be wandering in hallway. Nurse asked where patient was going, patient replied that bathroom was full so going to another bathroom. Patient noted to be now wearing a winter coat. Nurse escorted to bathroom next to Room 25. Patient started a fire in trashcan in bathroom, and pulled fire cord. Nurses ran to check bathrooms. RN found trash can ablaze, and used fire extinguisher and put fire out. Entire ER was smoke filled. When staff asked the patient the reason for starting a fire patient stated that they did it for attention. Police and Firefighters were on scene shortly after. Pt fully oriented x3, and repeated this to Police and Fire Marshall. Lighter taken for evidence. Coat and jacket returned to its rightful owner in Room 14."
MR1 lacked documentation related to using the Safety Observer Algorithm, attempting alternative strategies, visual observation at 15 minute intervals and assessment, development, and evaluation of the plan of care for the patient before November 30, 2021 at 0300.
Close Observation Form completed November 30, 2021 revealed, "Level II-Constant Observation ... Type: Suicide Precautions" was documented for visual observation every 15 minutes from 0300 to 1300.
Close Observation Form completed November 30, 2021 revealed, "Type: Other: Behavior was documented for visual observation every 15 minutes from 1300 to 1515. No documentation was noted to indicate the level of observation.

EMP4 was not able to produce a copy of the Close Observation Form and the Safety Observer Screening and Request Form from the time frame of November 29, 2021 at 2357 to November 30,2021 at 0300.
EMP2 confirmed the physician order for continuous observation when shown in MR1. When EMP2 was asked for a policy related to continuous observation EMP2 stated, "We do not have a policy for just continuous observation, just close observation."

Cross Reference:
482.13 Patient Rights