Hospital patient dies in waiting room due to policy violations

A new report concludes that a patient died in the waiting room of a Pennsylvania hospital, unnoticed for more than 40 minutes after he died, because the hospital committed numerous violations of State Department of Health policy.

On Nov. 28, 2009, Joaquin Rivera entered the waiting room of the emergency department of Aria Health's Frankford campus. Rivera, 63, entered the ED at 10:45 p.m. complaining of pain on his left side. According to the state report prepared as a result of investigating the incident, surveillance footage showed Rivera stopped moving at 10:56 p.m.

Seven minutes after that, a hospital staffer called Rivera's name and noticed him staring at a wall, she told investigators for the state. Despite this, no hospital personnel checked further to see if Rivera needed medical help. In fact, hospital staffers didn't become aware of Rivera's condition until another patient told them what was going on--and by that point, Rivera's corpse had been robbed of his watch by vagrants, the state concluded.

The report concludes that the triage nurse appeared at the patient waiting room door entrance, but didn't enter between 10:45 p.m. and 11:47 p.m. to check on patient activity.

Since the incident, which the hospital investigated independently, the hospital suspended the triage nurse and a registrar who offered conflicting accounts of what took place that night in the waiting room.

According to the state report, hospital leaders swore to take several corrective actions, including establishing a program to retrain staff on hospital policies; marking, with tape, a spot to where workers could walk to view the entire waiting room; maintaining a 24/7 security presence in the waiting room; and setting a defined time frame for recalling patients back to be triaged and treated.

To learn more about this incident:
- read this Philadelphia Daily News piece

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