State cites Waterbury Hospital for lapses

Patient’s ER death among cases in report
Michael C. Juliano
April 16, 2017

WATERBURY – Waterbury Hospital failed to follow procedures in the case of an emergency room patient who died in August, as well as in seven out of 10 other cases randomly selected for review, the state Department of Public Health has ruled after an investigation of the man’s death.

Some of the errors involved paperwork lapses and procedures which may have contributed to long wait times for care, according to the report.

However, state investigators did not blame the hospital’s shortcomings for the cause of Abip Sadiku’s death, which the Office of the Chief Medical Examiner ruled as aortic dissection due to hypertensive cardiovascular disease.

The condition that Sadiku suffered is a tear inside the aorta, the main artery from which blood is pumped from the heart. It is associated with the sudden onset of severe chest or back pain and can quickly lead to death, according to studies published in medical journals. The condition gained national attention briefly in December when it killed actor Alan Thicke.

State investigators did find delays in treatment for Sadiku and three others which took longer than the national standards by which the hospitals are judged. Sadiku was seen by a nurse who administered an electrocardiogram at 7:21 p.m. to rule out an acute cardiac event.

Another registered nurse drew his blood at 8:49 p.m. and gave him Maalox and Lidocaine without a doctor’s order. State health care regulations do not permit registered nurses to prescribe medication.

SADIKU DIED IN THE HOSPITAL’S emergency department Aug. 26. His wife filed a complaint with the state health department, prompting unannounced visits to the hospital in early September.

The state implemented a Hospital Performance Improvement Plan. Results will be reported quarterly at a Performance Improvement Safety Committee meeting for monitoring and oversight.

Waterbury Hospital acknowledged the state’s plan in a letter Oct. 28, and sent a revised action plan in January.

According to a form completed by investigators marked complete on Sept. 14, the state inspectors reviewed Sadiku’s records, and nine other randomly selected patient records, within two weeks of his death. The other patients, who are not identified in the report, also entered the hospital emergency room for chest pain.

AMONG THE STATE investigation’s findings:

The hospital failed to obtain a doctor’s order before giving Sadiku medication to treat heartburn and to reassess the vital signs for five emergency room patients in accordance with policy.

Sadiku, 49, was admitted into the emergency room by ambulance at 7:15 p.m. Aug. 26. He had been brought there from his Woodbury home after complaining of severe upper-chest pain. He told medics his pain was level 10 of 10 and a blood pressure test indicated he was hypertensive. Because all 37 emergency room beds were occupied, he was placed on a stretcher in the hallway of the triage area, where he stayed until he stood up and collapsed suffering a cardiac arrest at 10:01 p.m. He was pronounced dead at 10:21 p.m., the records show.

The Department of Public Health investigation found that three of 10 patients who showed signs of abdominal pain and additional signs of severe pain including hypertension, tachycardia, diaphoresis, agitation and pupil dilation waited longer than the standard five minutes to be evaluated by a doctor or another provider, such as a licensed practical nurse, who is able to provide care without direction or supervision of another. Three registered nurses saw Sadiku before his death, but they are not licensed independent practitioners, according to state health care guidelines.

The hospital has established triage levels of one through five with one being the most severe. In Sadiku’s case, a nurse set his triage level as three high, or that the patient was not in “severe distress.”

The director of the emergency department told state investigators that if the vital sign alert was identified by the triage nurse as “yes,” the patient’s triage level would have been a “two” and ultimately led to a timely evaluation,” the report states.

Sadiku was not seen by a licensed independent practitioner until he collapsed at 10:01 p.m. – 2 hours and 46 minutes after arrival.

Hospital policy says that if a doctor or other licensed provider is not available within five minutes, the nurse would ask a doctor to make themselves available, and if one was not available the emergency room medical director should be immediately notified.

Records and staff interviews revealed four of 10 patients who were triaged as a level two with a vital sign alert failed to be seen within five minutes. The report states patients waited for 39 minutes, 19 minutes, 49 minutes and 32 minutes.

THE AVERAGE WAIT TIME at Waterbury Hospital is 65 minutes, the highest median wait time in the state, according to data collected on 26 hospitals in 2014 and 2015 by the Centers for Medicare & Medicaid Services. State and national median wait times for other emergency departments which see 40,000 to 59,999 each year are 28 minutes.

Waterbury Hospital treats 51,000 emergency patients each year, according to Patricia Charvat, hospital spokeswoman.

“All patients who come to the (emergency department) are evaluated as quickly as we are able,” Charvat said. “In all cases, we make all efforts to quickly assess the level of severity or complexity of a patient’s condition upon their arrival at the (emergency department).”

She said the hospital has been working to improve its process of evaluating and assessing patients needs.

“It is important to note that the amount of a time a patient spends in the (emergency department) is, in part, dependent on their symptoms, tests required, and course of treatment,” she said. “It takes time to conduct tests and receive the results back. It takes time to identify the proper course of treatment.”

During the investigation and before the case was closed in January, ownership of Waterbury Hospital changed. Prospect Medical Holdings Inc. became owner of the hospital’s parent Greater Waterbury Health Network on Oct. 1. Any changes required by the state following the Sadiku investigation are carried on to new ownership, according to state health care statutes.

Among the new owners’ first priorities was to improve and expand the emergency department. The hospital has hired a firm to plan a $3.75 million upgrade.

Maura Downes, health department spokeswoman, said the agency receives about 1,500 complaints a year for all health care facilities, including hospitals, nursing homes and doctor’s offices. Downes said about 80 percent of the complaints are investigated following federal protocol that allows inspectors to enter the health care facility without telling the operators details of the complaint.

THE STATE HEALTH DEPARTMENT follows a “State Operations Manual” compiled by the federal Department of Health and Human Services Centers for Medicare & Medicaid Services. It outlines procedures for what are called adverse events at health care facilities. The results of these investigations are public information once the case is closed and are shared with hospital administrators for the purpose of correcting deficiencies.

The Republican-American was provided a copy in February of the 15-page report by Joel Faxon, an attorney representing Sadiku’s estate. The family is considering a lawsuit, he said.

The Department of Public Health later released the findings and corrective measures after the Republican-American filed a Freedom of Information request for the documents.

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