DEATH IN WAITING ROOM: State probes ER fatality at CMC

A travel nurse’s contract was terminated and the New York State Department of Health has opened an investigation following the death of a patient last month in the Emergency Department waiting area at Cayuga Medical Center.

Cayuga Medical Center President and CEO John Rudd said the patient’s death occurred “as a result of a series of breakdowns” in procedure on Jan. 19, and changes in protocol began being implemented the following day. Rudd also added the hospital is fully cooperating with the Department of Health’s investigation. The names of the patient and nurse were not released.

According to CMC officials, the patient — a 52-year-old male — arrived to the Emergency Department at 6:07 p.m. by Bangs Ambulance after he was discovered sleeping on the floor of a convenience store. He had initially refused the ambulance, but EMS returned soon after speaking to the Ithaca Police Department and then talked the man into being checked out at the hospital. He was alert and communicating with staff upon arrival to the CMC, according to Vice President of Medical Affairs David Evelyn, who also noted the man got himself off the ambulance stretcher and into the wheelchair at the hospital.

When a patient comes to the Emergency Department, an assigned nurse performs triage to determine how quickly the patient needs to be seen, and a number between 1 and 5 is assigned. This includes a series of questions and a documentation of vital signs. A 1 is given to extreme emergencies like a heart attack or stroke, while a 5 is for ankle sprains or minor cuts. The man, who did not show any signs of distress at the hospital, was assigned a 4 by the nurse assigned to triage on Jan. 19 — the same female nurse whose contract would be terminated — and was wheeled into the waiting room. He was discovered unresponsive at 8:23 p.m. and ruled dead after an attempt to resuscitate him was not successful.

Evelyn said the hospital began investigating the incident the following day, including interviewing staff and patients in the area at the time, and viewing footage from security cameras to nail down the sequence of events.

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“Through the investigation, it became apparent the nurse falsified her triage documentation,” said Evelyn, who noted the Emergency Department was not overly crowded at the time. “She did not ask him those questions, she did not take those vital signs that she had put into the records, so she had falsified the records. On the tape, we can see (the patient) was looking around for a certain part of time he was there, but eventually, he just looks like he’s sitting there. People in the room said it appeared he was asleep.”

Evelyn said the CMC contacted the Department of Health and the medical examiner. The results of a forensic autopsy have not been released. Officials at the CMC have met with the man’s family several times to provide updates in the investigation, Rudd said.

The termination of the contracted travel nurse, who was not a new employee at the CMC, came as a result of video evidence and interviews, according to Rudd, who said the patient’s entire visit is on video except for three minutes in a patient care area, which does not have cameras.

“She said (triage) was done in the waiting room,” Evelyn said. “We see him in the waiting room, but the two hours he’s in the waiting room, the nurse doesn’t approach him at all. Vital signs are logged when he’s already in the room, and she was at a desk.”

Evelyn said the man’s vitals were not taken during the three-minute window he is not shown on camera, according to eyewitness testimony.

“She chose to put in falsified documentation as far as vital signs … when she never touched the patient,” said Deb Raupers, vice president of patient services and chief nursing officer, who added about a third of the nurses used are contracted. “That’s something that is reportable to the state under our nursing license. It has to go to the office.”

Raupers said the hospital has already made several changes to protocol and will continue to examine ways to change processes to prevent any similar incidents from occurring. The hospital now has an assigned triage nurse who will cover the waiting room area at all times, in addition to re-educating nurses about triage policy. The assigned nurse also will engage with the patients and reassess initial diagnosis after a certain amount of time.

Officials at the hospital also have introduced safety briefings for all shifts and re-education on the escalation process. Raupers said the hospital is also working with regional EMS about proper procedures when bringing patients to the Emergency Department. The hospital also split staff into four work teams to improve workflow in the waiting room, and get patients into a bed and with a provider faster. An external consultant is being brought in to evaluate all Emergency Department operations.

“Obviously, this is a serious event, and we view it as a defining moment for us to say how do we look at our processes and how do we change processes so something like this will never happen again,” Rudd said.

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