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his bed so he could eat what he wanted, when he wanted. Nurses would ask him what he wanted for dinner off his restricted menu and, with his trademark sarcastic scowl, he’d snap, “Give me two eggs, bacon, sausage, hash browns and coffee.”
    Stanley Jagodowski just didn’t get it.
    Months before his latest admission, on April 27, 1995, the bad habits Jagodowski had developed throughout the years had finally gotten the best of him.
    After an ongoing infection in his right foot failed to heal, doctors in Providence were forced to remove it. Three months later, on July 17, the infection spread throughout his entire right leg, and doctors had to amputate it just above the knee.
    Jagodowski had been transferred to Leeds to recover from the amputation. Paranoid, confused and bitter, he often moaned because the sound of it, he claimed, made him feel better. To stir up trouble, he’d lay on the nurse’s call bell until a nurse came into the room. As soon as she left, he’d do it again.
    But Jagodowski’s cynicism for life wasn’t without merit or irony. He’d survived the Korean War, was discharged from the Army in 1954, and lived a quiet life as a truck driver for decades. Yet here he was now, confined to a hospital bed and wheelchair, dependent upon other people to help him move his bowels, watching diabetes eat away at his body as though it were rust on a car.
    Despite his prior health problems, however, by August 21, 1995, things began to look up for the aging veteran. Only a month after his transfer from Providence, Jagodowski not only was feeling better, but he was looking healthier than he had in years.
    The amputation had apparently done the trick. So much so, that for the past week, he had been free from any injectable medicines—which was a significant sign of improvement in itself. When pain did come on and his stump began to throb—as Jagodowski would put it, “like five toothaches”—doctors prescribed oral treatments of Demerol, a painkiller.
    A week earlier, on August 14, doctors had agreed Jagodowski was doing so well that he could leave Ward C—the VAMC’s chronic ward—and transfer to the long-term nursing care unit of the hospital.
    The only thing standing in his way was the availability of a bed.
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    The Leeds VAMC has many different wards scattered throughout its complex of buildings, with Ward C located in the main building, Building One. The entire ward was shaped like the letter T. Down at the end of the hall—the top of the T—was a four-bed intensive care unit (ICU). There was a short hallway between the ICU and the L-shaped nurse’s station, where the charge nurse sat. With about thirty beds, the ward was split into teams and the workload divided up among the nurses on duty.
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    At about 7:00 P.M., on August 21, 1995, respiratory therapist Michael Krason gave Stanley Jagodowski a treatment of “three puffs of Albuterol,” a drug that helped patients breathe easier. Prior to August 21, Jagodowski had been receiving four puffs of Albuterol, however. With over twenty-three years’ experience, Krason agreed with everyone else that Jagodowski’s condition was improving. He wrote in his medical chart that he was “alert, his breath sounds were clear, he [was] in no distress, and his color [was] good.” To top it off, Krason also noted that Jagodowski showed no adverse reactions to the respiratory treatment.
    Near 8:00 P.M. , Jagodowski’s primary care nurse, Jeff Begley, asked fellow nurse Beverly Scott to assist him in getting Jagodowski ready for bed. Begley said he didn’t want to deal with the difficulties the heavyset Army vet was likely to create.
    Scott agreed to help.
    â€œHi, Mr. Jagodowski,” Scott said, entering his room. “How are you tonight?”
    â€œI’m fine, Beverly.”
    After straightening his bed linen and changing his gown, Scott and Begley