A Jefferson patient was severely burned after lighting a cigarette while on oxygen

Smoke smells filled the patient room at Thomas Jefferson University Hospital where a nurse was responding to an urgent bed alarm.

The patient had attempted to light a cigarette while receiving treatment that involved supplemental oxygen, which can cause materials near it to catch fire more easily. State records show the patient “felt something catch on fire” and extinguished the flames with a pitcher of water.

The patient had visible burns to their chest, upper lip, and nose, and the plastic tubing connecting the oxygen tank to their nose was partially burned and melted. The patient was treated in the surgical intensive care unit for first- and second-degree burns.

The Jan. 23 incident drew one of the Pennsylvania Department of Health’s harshest reprimands for the Center City hospital, the flagship of Jefferson Health’s 32-hospital system. The next day, health inspectors issued what the department deems an immediate jeopardy citation, indicating potentially life-threatening safety problems.

The health department said that Jefferson had failed to follow protocol for checking patients for smoking paraphernalia and informing them of no-smoking rules, which is required even though smoking in and around hospitals has been largely banned for more than three decades.

Jefferson staff did not document whether they had warned the patient about the risks of smoking while receiving supplemental oxygen, and failed to fill a doctor’s order for Nicorette lozenges, a nicotine replacement therapy, according to a February inspection report that became public in March.

The hospital should also have made sure the patient had not brought in smoking materials, such as cigarettes and a lighter, and secured them until the patient was sent home, inspectors said.

The citation was lifted three days later, after the hospital posted more “No Smoking” signs and retrained staff on treating patients who smoke. Jefferson updated its policies to require smoking screening for all patients when they are admitted to the hospital, and added fields to its electronic medical record to ensure staff follow protocol for securing smoking materials and administering nicotine alternatives, according to the inspection report.

Jefferson declined a request for additional comment. The inspection report describes the incident, but says nothing about the patient’s recovery.

» READ MORE: When quitting smoking feels like losing a best friend, this Philly-area program can help

On Jan. 23, a nurse rushed into the patient’s room, responding to the bed alarm and “immediately smelled burning smoke in the room,” according to the inspection report. There were burn marks and holes in the bedsheets, and a lighter was on the bed.

The patient had been admitted to the hospital two days earlier with a mass in their chest that was affecting their spine and causing numbness and weakness in their legs.

The inspection report does not give identifying details about the patient, such as their gender or age, and does not describe what medical treatment they received. However, it does indicate that the patient was receiving oxygen through a nasal cannula, a network of plastic tubing that delivers oxygen from a tank through the nose.

» READ MORE: Thomas Jefferson University Hospital cited after elderly patient goes missing

Jefferson prohibits smoking within 50 feet of medical facilities and requires its hospitals to post “No Smoking” signs in patient areas and notify patients when they arrive that smoking is not allowed, according to the inspection report.

During a tour of the hospital’s 9th floor comprehensive spine nursing unit, inspectors found no visible “No Smoking” signs in patient rooms where oxygen is administered.

In response to the citation, Jefferson posted “No Smoking” signs in the emergency department and in every patient room, at the foot of bed so the message would be at eye level.

The hospital developed a mandatory training session for nursing staff on the updated policies, and agreed to monitor compliance through random audits.