Cedars Cited for Ignoring Orders to Not Use Room Hit by Flash Fire

County health officials said Thursday that Cedars-Sinai Medical Center had violated repeated orders over the last two years to stop using the room where a flash fire killed a premature infant who was undergoing surgery 2 1/2 months ago.

“Room 4225 had been routinely used for neonatal surgery . . . despite the fact that the department had cited the facility in April, 1986, for unapproved use,” according to a citation issued by the county Department of Health Services.

Officials acknowledged that the room’s use apparently had nothing to do with the fire. Fire officials blamed the blaze on leaking oxygen from an unknown source. They said the oxygen was ignited by a pen-like cauterizer that emits a tiny spark to seal tissue.

Cedars-Sinai spokesman Ron Wise blamed the citation on a misunderstanding. He said that in 1986 the Health Services Department told the hospital not to use Room 4225 to house patients. But he said that order was followed. Patients were not housed there, he said. The room was used only for corrective heart surgery on premature infants.

The room has not been used since the fire, Wise added.

The 2-week-old infant died Oct. 6 as doctors were performing what hospital officials called a routine 30-minute operation.

The procedure--sealing a blood vessel that had failed to close at birth--had been done dozens of times in the room without mishap, Wise said.

But Robert Karp, program manager for the Health Services Department, said hospital officials should have known the department’s position that the room had not been approved for surgery.

Karp said health officials had warned the hospital several times in the past year that the room was not to be used for “patient care.”

In response to the latest citation, the hospital must prepare a use plan for the room, Wise said. That should end the dispute, he said.

But Karp said that if health authorities determine that hospital officials deliberately violated orders to stop using the room, the case could be referred to the city attorney for possible criminal prosecution.

Filing criminal charges in such cases is rare, Karp said.