Chicago hospital cited for patient death amid ED staff shortage

In February, a patient died at Loretto Hospital — a safety-net hospital on Chicago's West side — after no one was around to treat the individual in the emergency department, according to a CMS inspection report. 

CMS conducted an onsite investigation in late March after receiving complaints surrounding the incident and issued an immediate jeopardy citation, which was lifted in April. According to the report, a patient walked into the emergency department alone on Feb. 24 at 11:18 p.m., filled out a complaint form and placed it in the form box on the triage nurse's door. The patient's chief complaint was "cardiac emergencies," and the patient had a history of schizophrenia, hypertension, diabetes and heroin use. 

Video surveillance showed there was no staff around when the patient entered the ED waiting room, according to the CMS report. After filling out the triage form, the patient went into the bathroom near the triage nurse's door. A triage nurse came out and reviewed the form while the patient was in the bathroom and did not approach or knock on the door, and went back to the triage room. The patient came out of the bathroom for a moment and then returned. About 15 minutes later, a patient safety officer opened the bathroom door, just as the triage nurse came back out. 

They found the patient face down, and the officer "nudged" the patient to check for responsiveness. The patient was then placed against the door in a sitting position and was left unattended while staff went to get a wheelchair. "There was no resuscitate measures/emergency interventions initiated at that time," the inspection report said. 

An emergency department tech showed up to take the patient back to the treatment area. CPR was initiated and Narcan was administered. The patient was intubated and transferred to the critical care unit at 8:15 the next morning. According to the documents, the patient's mother was called, who gave consent to not resuscitate and the patient was pronounced dead at 7:30 p.m.

In the report, the hospital acknowledged "staffing challenges" and confirmed the waiting area and triage room were staffed by one nurse when the incident occurred. "Loretto Hospital recognizes this poses a risk from a patient safety standpoint," the hospital said in its corrective action plan. Loretto developed a plan of correction that included ensuring the triage waiting area is monitored by a clinical staff member at all times, ensuring timely and appropriate medical screening and re-educating ED staff on the importance of providing immediate life support, such as CPR. 

Inspectors conducted a follow-up visit April 20, and the immediate jeopardy warning was lifted. 

About 200 unionized workers at Loretto Hospital began an open-ended strike July 31, alleging a "significant staffing crisis" and substandard wages. In a statement previously shared with Becker's, a hospital spokesperson said the strike is solely "about money, not patient safety," adding that non-union employees have not received salary increases in three years and some took a pay cut to prevent layoffs. 

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