The University of Maryland Medical Center was not adequately enforcing its nonsmoking policy when a man died in a fire last fall at the hospital, according to a federal and state investigation.
Investigators discovered cigarettes and a lighter near the man's hospital bed after the fire.
"The facility staff failed to provide a safe and hazard free environment by not enforcing the facility smoking policy and/or maintaining a hazard free smoking area," investigators wrote in a report released this week.
Hospital officials said in a statement that they have since implemented "a more stringent" tobacco-free policy that focuses on how to manage noncompliant patients and visitors. Among the changes is around-the-clock monitoring of patients who don't follow the rules.
The state's office of Health Care Quality is monitoring the hospital's implementation of the new policy. If the state agency doesn't approve of the changes, the hospital risks losing its Medicare eligibility.
William Turner, 53, died in November after a fire started in his hospital bed on the 11th floor of the downtown Baltimore hospital. The cause was never determined conclusively, but fire investigators discovered a disposable lighter and a cigarette butt on the floor around the bed and a pack of Kool cigarettes in a bag on the back of a wheelchair.
At the time, hospital policy prohibited smoking in any room where flammable liquids, combustible gases or oxygen were used or stored, according to results of the investigation overseen by state health officials for the federal Centers For Medicare and Medicaid Services. The facility also made designated smoking areas available throughout the hospital with ashtrays made from noncombustible material.
Turner violated the policy, even after he was told about it, according to the report. On one occasion, a nurse noted cigarettes in the room and ashes in a cup. On another occasion, a nurse smelled smoke in the room and was told by Turner that he started to smoke and put it out. A doctor also found Turner smoking in the room.
While at the hospital, Turner, who had "difficulty with memory and mood," also pulled a knife on a nurse, according to the report. He told staff he was not himself and thought people were trying to harm him, the report said.
The state report said that medical records did not indicate that staff members offered Turner a nicotine patch or smoking-cessation class to help him with his smoking. The policy at the time also did not outline how to manage a patient who smoked despite the rules.
"The failure to address the patient's behavior not only placed the patient at risk, but other patients as well," the report concluded. "The failure to assess and manage the patient's risky behavior of smoking in his room ultimately led to a fire and the patient's death."
The investigators found that staff at all levels — nurses, doctors, security, management — did not adhere to the smoking policy, according to the report.
"We have communicated to CMS our plan of correction for the items they found during the survey process and will continue to work with CMS as they complete their review of the actions we have taken," the statement from the hospital said.
Turner, who was paraplegic, died of smoke inhalation and burns that caused complications to his underlying hypertensive cardiovascular disease, according to an autopsy report. His death was ruled accidental. The fire burned the mattress as well as envelopes and magazines, and continued to burn the bedding and Turner's lower extremities.
Investigators said the cause of the fire could "not be fully ascertained" but ruled out an equipment malfunction or arson. They said the fire caused $30,000 worth of damage.
Hospital staff extinguished the fire before firefighters arrived.
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