Abstract: On August 10, 2011, Employee #1 was working as a respiratory therapist for Sutter General Hospital in Sacramento, CA. She was working with a patient in the fourth floor telemetry unit in wing 4 South of the hospital. This was one of the many carpeted sections of the hospital. When she arrived, an EVS (environmental services) worker was using a Tennant ride-on carpet extractor to clean the carpet. He was using the cleaning agent Betco FiberPRO Red and Brown Out, a chemical containing hydrochloric acid and hydrogen fluoride. Employee #1 began coughing, but she was able to work with her patient with the door closed. She returned four hours later to work with the patient again, and this time, the carpet blowers had been set out to dry the carpet. Employee #1's reaction was worse than before, and she had to go to the emergency room. She sustained serious respiratory distress requiring hospitalization for more than 24 hours.