Wernersville State Hospital

“General Requirements - Other CFR(s): NFPA 101 General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 43410 28 Pa. Code § 201.14(a). RESPONSIBILITY OF THE LICENSEE (a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents. This REGULATION has not been met. 35 P.S. § 448.808. Issuance of license. (a) STANDARDS - The Department shall issue a license to a health care provider when it is satisfied that the following standards have been met: (2) that the place to be used as a health care facility is adequately constructed, equipped, maintained, and operated to safely and efficiently render the services offered. Based on document review, observation and interview, it was determined the facility failed to meet the minimum standards for the operation of a facility, as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents within the component. Findings include: 1. Review of documentation, observation and interview on July 23, 2024, between 10:00 AM and 12:00 PM, revealed the facility portable life safety drawings of lacked door swings, resident room capacities and hazardous areas delineated. Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the available floor plans lacked some of the required information.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 22744 Based on observation and interview, it was determined the facility failed to maintain exit access to be readily accessible, on one of four floors within the component. Findings include: 1. Observation on July 23, 2024, at 1:00 PM, revealed the 3rd floor Activity Room 341 and 342 doors could be locked against egress, with an unseen leaver in the knob set, which did not automatically release. Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:00 PM, confirmed the doors could be locked against egress.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 43410 Based on observation and interview, it was determined the facility failed to maintain self-closing doors, to be free of obstruction from closing, in one of five smoke zones within the component. Findings include: 1. Observation on July 23, 2024, at 1:20 PM, revealed the door, to B Wing Activity Room 134, was held open with a folded paper plate, on the 1st floor. Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the door was wedged open.”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 22744 Based on observation and interview, it was determined the facility failed to maintain stairtower doors to positively latch, to be within the allowed gap margins, and to be capable of self-closing, on three of four floors within the component. Findings include: 1. Observation on July 23, 2024, between 11:25 AM and 1:05 PM, revealed stairtower doors failed to positively latch, at the following locations: a. 11:25 AM, 4th floor, the double doors to Stairtower #4, did not latch; b. 1:05 PM, 2nd floor, the double doors to Stairtower #3, did not latch, when closed; Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the stairtower doors failed to positively latch. 2. Observation on July 23, 2024, between 11:30 AM and 1:30 PM, revealed stairtower doors had gaps that exceeded the allowed gap margins, at the following locations: a. 11:30 AM, 4th floor, the stairtower to the Penthouse, had gaps, greater than 3/16 inch; b. 12:10 PM, 3rd floor, the #2 Stairtower door, had gaps, greater than 3/16 inch; c. 1:30 PM, 2nd floor, the #5 Stairtower door, had gaps, greater than 3/16 inch; Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the stairtower doors exceeded the allowed gap margins. 3. Observation on July 23, 2024, at 12:25 PM, revealed Stairtower 1 doors were hitting on the meeting edge and failed to self-close. Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the door failed to self-close.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 22744 Based on document review and interview, it was determined the facility failed to perform functional tests of battery-powered emergency lighting source, at the generator, which serves the entire component. Findings include: 1. Review of documentation on July 23, 2024, between 10:00 AM and 12:00 PM, revealed the facility lacked documentation, verifying the Generator Room battery back-up emergency lighting was tested for 30 seconds a month and 90 minutes annually. Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the facility failed to record the monthly and annual testing.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 30411 Based on observation and interview, it was determined the facility failed to maintain the smoke resistance of hazardous area enclosures, affecting one of five floors within the component. Findings include: 1. Observation on July 23, 2024, at 1:16 PM, revealed the door, to 1st floor Storage Room 138, failed to automatically close and positively latch within the door frame. Interview with Maintenance Repairman 1 on July 23, 2024, at 1:16 PM, confirmed the door did not automatically close and positively latch within the frame.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 43410 Based on observation and interview, it was determined the facility failed to provide the hydraulic nameplate, and the sprinkler piping to be free of extraneous weight, affecting the entire component. Findings include: 1. Observation on July 23, 2024, at 12:45 PM, revealed the sprinkler system lacked a hydraulic nameplate. Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the lack of a hydraulic nameplate. 2. Observation on July 23, 2024, at 12:50 PM, revealed multiple wires attached to the sprinkler bracket and sprinkler pipes, above the ceiling, by the Horticultural Room. Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed various items attached to the automatic sprinkler system.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 22744 Based on observation and interview, it was determined the facility failed to ensure that corridor doors would properly close and resist the passage of smoke, on two of four floors within the component. Findings include: 1. Observation on July 23, 2024, between 12:20 PM and 1:10 PM, revealed corridors doors were hitting the frame and could not be closed, at the following locations: a. 12:20 PM, 3rd floor, Resident Room 319; b. 12:42 PM, 3rd floor, Clean Linen 366; c. 12:43 PM, 3rd floor, Resident Room 364; d. 12:47 PM, 3rd floor, Resident Room 355; e. 12:47 PM, 3rd floor, Resident Room 354; f. 1:10 PM, 2nd floor, Big Day Room 206. Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the corridor doors were obstructed from closing. 2. Observation on July 23, 2024, between 12:35 PM and 12:40 PM, revealed corridors doors failed to positively latch in the frame, at the following locations: a. 12:35 PM, 3rd floor, Day Room 376; b. 12:40 PM, 3rd floor, Resident Room 371. Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the corridor doors failed to positively latch. 3. Observation on July 23, 2024, between 12:30 PM and 1:15 PM, revealed corridors doors had gaps, exceeding 1/2 inch, at the following locations: a. 12:30 PM, 3rd floor, Resident Room 315; b. 12:44 PM, 3rd floor, Smal Kitchen 361; c. 12:44 PM, 3rd floor, Resident Room 353; d. 1:15 PM, 2nd floor, Room 211. Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the corridor doors had gaps, greater than 1/2 inch.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 22744 Based on observation and interview, it was determined the facility failed to maintain the smoke barrier doors to self-close, in two of three smoke compartments within the component. Findings include: 1. Observation on July 23, 2024, at 12:00 PM, revealed the 3rd floor smoke barrier door self-closing device had been disconnected, by Room 303. Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the closure was disconnected.”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 30411 Based on observation and interview, it was determined the facility failed to maintain components of the electrical hardware, affecting the entire component. Findings include: 1. Observation on July 23, 2024, at 11:49 AM, revealed an open electrical junction box, located on Walk-In Unit #2, by the exterior exit door. Interview with Maintenance Repairman 1 on July 23, 2024, at 11:49 AM, confirmed the junction box was not covered.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 22744 Based on observation and interview, it was determined the facility failed to maintain the HVAC system, to have a closed plenum system, affecting one of four floors within the component. Findings include: 1. Observation on July 23, 2024, at 11:25 AM, revealed the 4th floor exit egress corridor was used as a return air plenum for Rooms 401, 402, 406, 408, 410, 414, 415, 416, 417, 418, 419 and 420. Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the corridor was used as a return air plenum.”

“Elevators CFR(s): NFPA 101 Elevators 2012 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter’s Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter’s Service Requirements of ASME/ANSI A17.3. (Includes firefighter’s service Phase I key recall and smoke detector automatic recall, firefighter’s service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19.5.3, 9.4.2, 9.4.3 This Standard is not met as evidenced by: 43410 Based on observation and interview, it was determined the facility failed to maintain self-closing doors to positively latch, affecting one of one elevator machine rooms within the component. Findings include: 1. Observation on July 23, 2024, at 12:35 PM, revealed Elevator Machinery door failed to latch in frame, due to dragging on the floor. Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the door failed to latch in frame.”

“Soiled Linen and Trash Containers CFR(s): NFPA 101 Soiled Linen and Trash Containers Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended. Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent. 18.7.5.7, 19.7.5.7 This Standard is not met as evidenced by: 22744 Based on observation and interview, it was determined the facility failed to provide a protected space for soiled-linen and trash containers, exceeding 32 gallons, in two of three smoke compartments on the 3rd floor within the component. Findings include: 1. Observation on July 23, 2024, between 12:05 PM and 12:55 PM, revealed soiled-linen and trash containers were stored in shower rooms, which did not have a 1-hour protected rating, at the following locations: a. 12:05 PM, Women’s Shower Room 338; b. 12:55 PM, Shower Room 348. Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the soiled-linen/trash was not stored in a rated assembly.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 22744 Based on observation and interview, it was determined the facility failed to maintain rated doors, to be repaired with approved accessories per NFPA 80, in one of three smoke compartments on the 3rd floor within the component. Findings include: 1. Observation on July 23, 2024, at 12:20 PM, revealed the door, to Supply Room 328, had penetrations filled with putty. Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the door was filled with an unauthorized filler.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 22744 Based on document review and interview, it was determined the facility failed to verify the emergency generator fuel sample test had been completed, affecting the entire component. Findings include: 1. Review of documentation on July 23, 2024, between 10:00 AM and 12:00 PM, revealed the facility failed to verify the quality of the emergency fuel reserve test had been performed, within the previous twelve months. Interview at the time of the exit conference with the Facilities Operations Manager, Safety Manager and Fire Marshall on July 23, 2024, at 1:30 PM, confirmed the facility could not provide verification whether the fuel test had been completed.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 30411 Based on observation and interview, it was determined the facility failed to monitor the use of surge suppressors and receptacle multipliers, affecting one of four floors within the component. Findings include: 1. Observation on July 23, 2024, at 12:20 PM, revealed a surge suppressor was supplying electrical power to another surge suppressor, in the basement I.T. Phone Room (Room 4). Interview with Maintenance Repairman 1 on July 23, 2024, at 12:20 PM, confirmed the daisy-chained surge suppressors. 2. Observation on July 23, 2024, at 12:39 PM, revealed a receptacle multiplier supplying electrical power to an extension cord in the basement Auditorium. Interview with Maintenance Repairman 1 on July 23, 2024, at 12:39 PM, confirmed the use of a receptacle multiplier.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42111 The information reviewed during the unannounced complaint investigation survey on July 1, 2024, provided evidence that the facility failed to substantially comply with this Condition of Participation by failing to provide a safe environment for patients. A patient was able to obtain contraband (some type of lighter) and set fire to the facility that caused environmental damage and put all patients at risk for serious injury. A discussion took place with the survey team and the facility’s administrative staff regarding the survey team’s concerns related to Patient’s Rights on July 1, 2024, at 11:00 AM. The Immediate Jeopardy was called at 11: 30 AM on July 1, 2024. The facility submitted an acceptable Immediate Jeopardy Removal Plan at 5:35 PM on July 1, 2024. The Immediate Jeopardy was removed on-site on July 1, 2024. Condition of Participation non-compliance remains. The surveyor validated the Immediate Jeopardy Removal Plan was substantially implemented by education documentation, policy and procedure revisions, and interviews. Cross reference §482.13 (c)(2) Patient Rights: Care in a Safe Setting”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 42111 Based on review of facility documents, tour, video footage, medical record (MR) and interviews with staff (EMP) it was determined the facility failed to maintain a safe setting for patients by not preventing a patient from accessing contraband (some type of lighter) which was used to start a fire. Prior to the fire the patient was found smoking on the nonsmoking premises and the facility failed to determine how the patient got the lighter or if more was accessible. In addition, the facility failed to follow their search policy to remove all contraband. The fire put all patients at risk for serious injury. Findings: Review on July 1, 2024, of facility policy, “Consumers Rights and Grievance and Appeal Procedure” dated December 2022, revealed “The purpose is to ensure that the rights guaranteed to consumers are safeguarded. ...” Review on July 1, 2024, of facility policy “Searches of Visitors and Consumers” dated July 2022, revealed “Wernersville State Hospital maintains a safe, therapeutic environment free from materials which are counterproductive to recovery. ... Conducting searches for contraband or restricted items is done after all alternatives to insuring safety are exhausted ... Definitions: A. Contraband - Contraband shall include anything which would be illegal or dangerous in the possession of a consumer. Items identified below are illegal, dangerous independently, or a danger when mishandled in the hospital setting potentially jeopardizing the personal safety of consumers, employees, and visitors. B. Contraband Prohibited by the Facility - Neither consumers nor visitors may bring any of the following into the facility, unless otherwise approved by Administration: Matches, lighters, tobacco, tobacco products ... Each search must be explained to the affected consumer(s) and conducted only for probable cause. Consent is always requested. ... If the consumer refuses to be searched, the physician will be contacted. The physician will insure a search over objection is clinically indicated and specify the rationale for such as well as the type of search needed in a physician ’ s order. Specific searches must be ordered by a physician by name of search, personal search, personal external body search, or living unit search. Searches are ordered for a single episode for a consumer at risk of harm to self or others. This order is time limited. The Nursing Supervisor is then contacted to secure approval from the CEO, designee, or Administrator-On-Call and to brief him/her regarding the need for the search over objection. ... VIII. Contraband Disposition - When facility staff discovers objects, devices, and substances which are taken from a consumer or visitor for health or safety reasons, the following steps must be followed: A. Documentation, Receipts and Reports. All searches and the results thereof must be documented. ... completion of an entry in the Interdisciplinary Progress Note covering: 1. Date & Time 2. Authorization 3. Specific Reasonable Cause 4. Natural/Type of Search 5. Conducted by 6. Consent obtained (if so, from whom, if not, why?) 7. Result of search ... Tour of facility on July 1, 2024, at approximately 1:00 PM, revealed that building 35 (wing four) contained three patient rooms which had smoke and fire damaged from the fire that occurred in the facility on June 27, 2024. Wing four had windows boarded up and several large floor fans used to remove the smell of smoke. During the tour EMP 4 explained wing four requires clean up, reconstruction and the timeframe to restore wing four will take approximately 8 months. Review of video footage on July 1, 2024, at approximately 11:00 AM revealed footage from June 27, 2024, starting at 1:45 PM and ending at 1:55 PM. The footage showed Patient (MR1) and staff moving throughout the hallway (wing four). The origin of the fire was observed. MR1 was walking to and from room private patient room. MR1 walked to and from room approximately four times in a row until smoke was noticed coming from the room. At that time, the unit began to evacuate. Review on July 1, 2024, of MRI revealed the patient was re-admitted to the facility on May 20, 2021, with a primary diagnosis of schizoaffective disorder, bipolar type and a history of arson. The review of the annual “Psychiatric Evaluation” dated April 23, 2024, revealed the patient continued to exhibit behaviors of low moods, urinating in room on clothing, smoking and/or smelling of smoke and grand delusions of being a doctor. Patient was adherent to medications but declined workshop and similar activities. Review of “Interdisciplinary Progress Notes” revealed on May 29, 2024, the social worker met with the patient to go over the hospitals rules of not smoking. On June 4, 2024, the patient was witnessed smoking by security and the doctor was notified. No documentation or physician order was found in the MR that a search was conducted. Further review of MR1 revealed the patient admitted to starting the fire that occurred on June 27, 2024. Note in MR1 states the patient admitted to fire starting due to anger related to not being able to smoke. The patient admitted to knowing and having full intent of fire spreading from personal bedroom. The patient stated “I was hoping it would. I was lighting the sheets and blankets on fire. I would rather be in jail.” After the fire the hospital documented that they reduced privileges to limit the risk of further access to fire starting. Interview on July 1, 2024, at approximately 11:15 AM with EMP1 revealed on June 4, 2024, patient was seen smoking on the side of building 9 which was witnessed by EMP2. In addition, patient was suspected of smoking on several other occasions. Interview with EMP 3 at approximately 3:30 PM confirmed there was no official documentation or physician orders to show a search took place after the patient was found smoking and the facility did not follow their “Searches Of Visitors and Consumers” policy.”