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									          REPORT TO THE




            FEBRUARY 2, 2010


                    submitted by

              Thomas R. Kline, Esquire


          prepared under the supervision of

         Mark A. Hoffman, M.D., J.D., LL.M.

                Kline & Specter, P.C.
                                   EXECUTIVE SUMMARY

       On the night of November 28, 2009, Joaquin Rivera died in the waiting area of the

Emergency Department of the Aria Health, Frankford Campus [“Frankford Hospital”] while

awaiting medical evaluation and treatment. Mr. Rivera presented to the Emergency Department with

complaints of left-sided pain, and died within hours of his arrival at the hospital, within feet of

appropriate triage and life-saving medical care. Mr. Rivera received neither, reflecting a multi-level

failure of the patient intake and surveillance system within the Emergency Department.

       The totality of Mr. Rivera’s Emergency Department visit was captured by the hospital

videotape security system. The events surrounding Mr. Rivera’s death have been the subject of

intense media scrutiny and public outrage, compounded and amplified by the theft of Mr. Rivera’s

wrist watch while he was dead or dying unattended in the Emergency Department waiting area. His

death has been the subject of internal hospital review, and public agency investigation.

       Recently, the Pennsylvania Department of Health issued a report highlighting severe systems

breakdowns and deficiencies at the interface between the public and the Frankford Health

Emergency Department. That analysis, while forensic in nature and comprehensive in scope, adopts

the narrow focus of a systems analysis at interface between the patient and medical care, without a

down-stream context. This report compliments and extends the investigation by the Department of

Health report, and undertakes a broader, and more substantive, analysis of the medical context of

these events. Outside analysis, in anticipation of litigation, was obtained by prominent medical

experts in the fields of emergency medicine and hospital administration. The findings and opinions

of these experts are incorporated into this report.       The report concludes with a series of

recommendations designed to avoid the shocking and preventable events of November 28, 2009.

                                   STATEMENT OF FACTS

Biographical Sketch

       Joaquin Rivera1 was born in the mountain town of Cayey, Puerto Rico, in 1946. He was the

youngest of eleven children. In 1964, at 18 years of age, Joaquin moved to Philadelphia. There, he

began working in a fabric laminating factory. In the evenings, Joaquin studied English courses, and

prepared for a Graduate Equivalent Degree. He also studied at the Community College of

Philadelphia and Rutgers University.

       Joaquin married his wife, Maria, in 1971. They have three children, Joaquin, Jr., Inez Rivera,

and Brenda Masino, and three grand-daughters. At the time of his death, his daughter Brenda was

expecting Joaquin’s fourth grandchild.

       For 32 years, Joaquin was employed at the Olney High School as a bilingual counselor-

assistant. He worked to place students on the road to a college education. He was also a self taught

guitarist, and a popular musician in the Puerto Rican community. Joaquin was an advocate for

sustaining Puerto Rican folk arts, culture, and music in Philadelphia.

       Joaquin was such a well-known figure in the community that he is featured in a mural of

Latino musicians on a wall at 5th and Somerset Streets in North Philadelphia. He lead a musical

ensemble called “Los Pleneros del Batey.” This musical group performed at schools, hospitals, and

senior centers, bringing the message and joy of Latin music into the community at large. Joaquin

composed a song entitled “Philadelphia, I Chose to Stay in My Home,” which was recorded for a

documentary produced by the Community Leadership Institute and Folklore project. A highlight of

           Photographs of Joaquin Rivera are attached as APPENDIX “A.”

his musical life was when Senator Edward Kennedy from Massachusetts played Joaquin’s guitar at

the Hispanic Reunion held for then Democratic Presidential Candidate John Kerry.

       Throughout his lifetime, Joaquin was an iconic figure in the Latin community. He received

numerous awards in celebration, recognition, and honor of his many contributions to the Philadelphia

community.2 He was named among the Delaware Valley’s Most Influential Latinos in 2009, in an

award program sponsored by the Impacto newspaper, Concilio, and the Philadelphia Multicultural

Affairs Congress.

Events of November 28, 2009

       On the evening of November 28, 2009, at 10:45 p.m., Joaquin Rivera presented to the

Emergency Department of the Frankford Hospital with complaints of left sided pain. Significantly,

Mr. Rivera had a medical history of high blood pressure and obesity, and a family history of

myocardial infarction. This medical history was never obtained by the healthcare providers in the

Emergency Department. In fact, following two visits to the registration desk, the last one occurring

at approximately 10:49 p.m., Mr. Rivera had no further contact with any personnel within the

Emergency Department while he was still conscious. Specifically, no triage evaluation, physical

examination, or screening history and physical assessment was performed on Joaquin Rivera by any

medical or nursing personnel of the Frankford Hospital prior to his being found in extremis.

       The Emergency Department waiting room area of the Frankford Hospital is equipped with

a surveillance video-camera, which captured the events of that evening. Mr. Rivera was seated

behind a pillar in the waiting room area. Only his abdomen and one of his arms is visible on the

           Joaquin Rivera’s awards are attached as APPENDIX “B.”

videotape. From 10:52 p.m. to 10:56 p.m., some movement of Mr. Rivera’s arm is discernible. At

approximately, 10:56 p.m., his abdomen can be observed heaving up and down heavily, and then his

arm becomes slumped in the chair’s armrest. There was no movement of the his abdomen or arms

observed after that time. At 10:57 p.m., examination of the videotape reveals a hospital security

guard walking through the waiting room and into a security office.

       By 11:09 p.m., Joaquin Rivera was the only person in the Emergency Department waiting

room area. At approximately 11:12 p.m., two individuals arrive, and sit immediately adjacent to Mr.

Rivera. At one point, a hospital security guard walks in and out of the Emergency Department

waiting room, and looks directly at Mr. Rivera. The security guard subsequently leaves the

Emergency Department area. at 11:25 p.m. The videotape shows one of the individuals who was

sitting next to Mr. Rivera removing Mr. Rivera’s wrist watch, and passing it off to an accomplice.

These individuals then leave the waiting room area.

       Mr. Luis Carrasquillo, a witness to the robbery of Joaquin Rivera, reported this event to the

Emergency Department staff at the Frankford Hospital. Mr. Carrasquillo also reported to the staff

that Joaquin Rivera appeared to be unconscious. At approximately 11:45 p.m., Joaquin Rivera was

found to be unresponsive in the waiting room area. He was transported to the treatment area in the

Emergency Department where resuscitative measures (cardiopulmonary resuscitation) were initiated

by, among others, John Sorrentino, M.D., the staff Emergency Department physician, and Siegfred

Soldevilla, R.N., an Emergency Department staff nurse.

       After approximately 20 minutes of attempted resuscitation, Joaquin Rivera remained

pulseless, with no obtainable blood pressure and no spontaneous respirations. Joaquin Rivera was

pronounced dead at or about 0004 hours on November 29, 2009.         The death was reported to the

City of Philadelphia Office of the Medical Examiner by Dr. Sorrentino. No autopsy was performed.

Edwin Lieberman, M.D., the Assistant Medical Examiner, listed the cause of death as “hypertensive

heart disease,” and the manner of death as “natural.”


       On December 16, 2009, the Pennsylvania Department of Health [“DOH”] released the Aria

Health Heath Inspection Results of an unannounced onsite compliance investigation completed on

December 4, 2009.3 The investigation was undertaken in response to Joaquin Rivera’s death at the

Frankford Hospital the preceding week.        The DOH found deficiencies with respect to the

requirements of 42 C.F.R. § 482 (Conditions of Participation for Hospitals)4 and 28 Pa. Code § 103,

109, and 117.5

       The salient findings reported by the DOH following their investigation highlighted the


        The Pennsylvania Department of Health Aria Health Inspection Results released December
16, 2009 [“DOH Report”] is attached as APPENDIX “C.”
        Promulgated by the U.S. Department of Health and Human Services, these regulations set
forth general requirements related to “the health and safety of patients” for hospitals participating
in the Medicare and Medicaid programs. See 42 C.F.R. § 482.11(a). “The hospital must meet the
emergency needs of patients in accordance with acceptable standards of practice.” See 42 C.F.R.
§ 482.55. The applicable regulations are attached as APPENDIX “E.”

         Promulgated by the Pennsylvania Department of Health, these regulations provide that
‘[e]very hospital shall have established procedures whereby the ill or injured person can be assessed
and either treated, referred to an appropriate facility or discharged, as indicated.” 28 Pa. Code §
117.12. Further, “[f]acilities for the emergency service shall be such as to ensure effective patient
care.” 28 Pa. Code § 117.31. The applicable sections of the Pennsylvania Code are attached as

                   1.   The governing body of the hospital failed to ensure that the facility
                        had sufficient personnel and followed facility policies to meet the
                        needs of the patients.6

                   2.   The Emergency Department failed to ensure that Emergency
                        Department services were provided to meet the emergency needs of
                        patients in accordance with acceptable standards of practice.7

                   3.   The hospital failed to ensure that the Emergency Department patient
                        waiting room was monitored to ensure effective and safe patient

                   4.   The hospital failed to ensure that the Emergency Department
                        performance improvement activities and policy and procedures were

                   5.   The hospital failed to ensure that an ongoing program for patient
                        safety and performance improvement activities in the Emergency
                        Department was followed.10

                   6.   Discrepancies in the statements of the triage nurse and the registrar
                        concerning the events surround Joaquin Rivera’s death, vis-a-vis, the

           DOH Report at 2.
           Id. at 5.
         Id. at 11. In this regard, it is repeatedly noted throughout the DOH Report that the
Emergency Department nurses were unaware of any policy for checking on patients in the waiting
room, or that maintaining an awareness of activity in the care area was in the Emergency Department
policies and procedures. See, e.g., id. at 16.
           Id. at 15.
          Id. at 17. The DOH Report noted that 8 % of patient of the patients left the Emergency
Department waiting area prior to receiving a screening. Further, there was no indication found that
this information was analyzed by the hospital’s Quality Assurance Committee, or that peer review
activity in the Emergency Department was being reported to the Quality Assurance Committee for
further action..

                            videotape record from that evening, resulting in a suspension of these
                            individuals pending a full investigation by the hospital.11

                   7.       The triage nurse failed to maintain an awareness of the activities in
                            the Emergency Department waiting room.12

                   8.       The Emergency Department failed to have a process for repeating
                            vital signs and assessment for patients in the waiting room, and to
                            monitor for changes in the condition of patients in the waiting room

                   9.       The hospital failed to provide sufficient personnel and observed
                            policies to meet the needs of the patients in the Emergency

                   10.      The hospital failed to provide Emergency Department Registration
                            Clerks who had knowledge of the Emergency Department policy and
                            procedures for the triage of Emergency Department patients.15

       Various deficiencies in medical record keeping and documentation were also underscored

in the DOH Report.16 Specifically referencing the care provided to Joaquin Rivera, it was noted that

there was “no documented evidence that the patient had been called for assessment by the triage

nurse.” Additionally, a review of the videotape surveillance tape showed that the Emergency

          Id. at 21. There is a note dated December 2, 2009 in Mr. Rivera’s Emergency Department
record which states: “11/28/09 2303 patient called to triage and no one answered to name.
11/28/2009 2332 patient called to triage for the second time and on one answered to the name
called.” It is interesting to note that the DOH report states that “[r]eview of [Mr. Rivera’s medical
record] revealed there was no nursing documentation that the patient had been called for assessment
by the triage nurse.” Id. at 22.
            Id. at 8.
            Id. at 9, 16.
            Id. at 35.
            Id. at 39.
            Id. at 42, 46

Department “triage nurse appeared at the patient waiting room door entrance and did not enter the

patient waiting room” and did not :monitor or maintain an awareness of activity in the ED patient

waiting room.”17 Joaquin Rivera died within feet of live-saving medical evaluation and intervention.


       Thomas R. Kline, Esquire, and the law firm of Kline & Specter, P.C., have been retained by

the widow of Joaquin Rivera, deceased, to investigate the death of her husband, and to prosecute the

civil action arising out of this death. Kline & Specter brings to bear two physician-lawyers who

practiced in the field of emergency medicine,18 as well as a general surgeon-lawyer with extensive

emergency department and trauma surgery experience.19 This matter was extensively “round-tabled”

internally, and forwarded for review to several prominent physicians holding board certification in

emergency medicine and other medical specialties. The case was also reviewed by a physician-

hospital administrator versed in emergency department policies and procedures, hospital protocols

and quality assurance, and the requirements, benchmarks, and requisites of the Joint Commission.20

       Any investigation and analysis of “what happened,” in terms of the substantial shortfalls in

Joaquin Rivera’s care, must be viewed within the dual context of “what should have happened” and

“why what should have been done, did not occur.” The Aria Health Policy and Procedure Manual

defines “emergency services and care” as:

            Id. at 52.
            Earlie H. Francis, M.D., J.D. and Carol Dembe, M.D., J.D.
            Mark A. Hoffman, M.D., J.D., LL.M.
            Formerly, the Joint Commission on Accreditation of Healthcare Organization (JCAHO).

                [A]n appropriate medical screening examination and evaluation...including
                ancillary services routinely available to the DED21 by a qualified individual to
                determine whether an emergency medical condition exists. If an emergency
                medical condition exists, Emergency Services and Care also includes the care
                and treatment by an Allied Health Professional...necessary to stabilize or
                eliminate the emergency medical condition.22

The provision of emergency care and services were, at their core, deficient.

        As a predicate consideration, it is palpably clear that Aria Health System knew the paradigm

for safe and effective cardiac care. Indeed, the Frankford Hospital, among other subdivisions of the

health system, held itself out as a cardiac center. The Aria Health System website acknowledges the

hospital’s responsibilities in this regard:

                 Aria provides first-rate emergency care in its emergency rooms and
                 emergency department at its Frankford, Torresdale, and Bucks locations.
                 Emergency care is a focus and a point of pride for Aria. Our staff of expert
                 emergency physicians, nurses, and other urgent-care professionals has
                 dedicated their careers to this type of medical care, in which cardiac
                 conditions are a critical area.

                 Aria's emergency teams are highly trained in identifying patients who arrive
                 with heart events, heart problems, or heart-related conditions. Our staff enters
                 such patients into an immediate system of care that precisely confirms the
                 source of the emergency condition and delivers the needed care promptly.
                 Time is often of particular essence in treating emergency heart patients. Our
                 emergency department works in close coordination with medical
                 cardiologists, electrophysiologists, interventionalists, and surgeons at Aria's
                 Heart Center. Unlike at some heart centers, these specialists at Aria are
                 available and accessible at all times to our emergency-medicine staff. And
                 today, such high-level teams are acutely aware of the "golden hours" at the
                 beginning of a heart event in which every minute can mean the difference
                 between full recovery or cardiac arrest, stroke, or permanent damage to the
                 heart. Whether the event is a heart attack, heart arrhythmia, or other problem,

          “DED” is a “Dedicated Emergency Department,” which is a department strictly dedicated
 to the evaluation and treatment of emergency care patients.
         ARIA Health Policy and Procedure Manual: Medical Screening Examinations, Stabilizing
 Treatment and Appropriate Transfers, effective: May 1, 2009 is attached at APPENDIX “D.”

our staff stands on its ability to get patients the right treatment as soon as
possible. The philosophy begins with close communication with the
emergency-medic and emergency-transport staff and continues throughout all
interventions and ongoing care.

Stopping the attack, limiting damage

It is said that "time is heart muscle" in heart attacks, because of the potential
for long-lasting damage to the heart wall for every minute that it is deprived
of proper blood flow. Such injury can permanently weaken the heart and
eventually lead to heart failure. With that in mind, our team uses the most
advanced emergency medical treatment, urgent cardiac catheterization, and
interventional or surgical care as needed. In this effort, we support our
certified cardiac-care professionals with the most up-to-date facilities,
technology, and resources. A similar approach guides our care of stroke

Our catheterization labs provide emergency angioplasty and stent placement,
with the back up of our surgeons and operating rooms for patients who require
surgical care. Our hospital inpatient cardiac unit provides dedicated care to
patients who need intensive, intermediate, or stepped-down care and recovery
from a cardiac event and treatment.

Entering into a system of care

Through any emergency phase of care, we pride ourselves on multidisciplinary
collaboration in the medical team and on communication with the patient and
family. Clearly explaining the patient's status, options, and needed steps of
care is essential for a cohesive experience where all care decisions are based
on a fully-informed, knowledgeable process.

Our emergency staff transitions care of Aria heart patients seamlessly to our
cardiac staff. As part of our heart center, these professionals are essential to
our carefully trained protocol for getting the right heart care to patients with
the most modern speed.

In addition to facilities at the Aria - Frankford and Aria - Torresdale locations,
Aria Health has recently expanded its emergency department at its Bucks
Campus, in conjunction with opening a state-of-the-science cardiac
catheterization laboratory at Aria - Bucks Hospital. Both projects meet the

                   growing demand for both cardiac and emergency services in Lower Bucks

        Aria Health System’s view of their role is in agreement with well defined and accepted

standards of emergency department and hospital care. Hospital emergency departments remain the

front line for care of patients who require emergency medical care, treatment, and stabilization.

Within the framework of the emergency department, a large volume of patients are seen across a

spectrum of illness acuities.24 While the emergency department can, and does, deliver healthcare

services to patients at all levels of illness severity, a systematic prioritization is necessary to ensure

that patients are timely seen based upon their level of urgency. In particular, as in Joaquin Rivera’s

case, some acute medical conditions are time sensitive in both their capacity for acute and

catastrophic deterioration, as well as the salutary effects of prescribed medical or surgical

interventions. This underscores the importance of the triage process, which comprised a major

component of the hospital’s failures in Mr. Rivera’s case.

        The word “triage” is derived from the French verb, “trier,” meaning “to sort,” or “to

choose,”25 and as the term stands, defines a process originally rooted in the battlefield care of

soldiers.26 The goal of triage is to prioritize illness to insure that medical assets and resources are

appropriately and timely utilized in the utilitarian sense of providing the greatest good to those in

         Aria Health: The Aria Health Heart Center (emphasis added). Accessed on January 30,
2010 at
        Gilboy N, Tanabe P, Travers DA, Rosenau AM, Eitel DR. Emergency Severity Index,
Version 4: Implementation Handbook. AHRQ Publication No. 05-0046-2. Rockville, Md:
Agency for Healthcare Research and Quality. May 2005 [“ESI Handbook”]. at 1.
             ESI Handbook. at 1.

need. As a general matter, patients with emergent, life-threatening, treatable conditions receive the

highest priority and most expedient and expeditious care. This system has been successfully

transitioned into civilian emergency departments with universal acceptance, and “is recognized as

“an essential component of safe medical care.”27 The goal of triage is to appropriately identify those

patients requiring emergent medical intervention and care.28

       Triage is a dynamic process, and acknowledges the nature of illness and the propensity for

certain “high risk conditions” to rapidly deteriorate.29 “Rapid, accurate triage of patients is key to

successful emergency department operations.         In particular, the triage nurse’s initial acuity

categorization is critical.    Under-categorization (under-triage) leaves the patient at risk for

deterioration while waiting.”30 Vigilance, however, for changes in a patient’s condition is also

paramount to effective emergency department operations.

       Chest pain and left sided pain are common presenting complaints among emergency

department patients. Joaquin Rivera’s initial complaints fell within the ambit of those highly

suspicious for cardiovascular and coronary events. The spectrum of chest pain and related clinical

problems and syndromes is broad. However, in Mr. Rivera’s age group, the working assumptions

must operate at the more dangerous and life-threatening end of the continuum of urgency. Indeed,

an acute coronary syndrome should have been at the top of the list.

            Gilboy, N. Triage. In: Sheehy’s Manual of Emergency Care (6th ed.2005) at 61.
         ESI Handbook. at 1; see also Gilboy, N., Travers D. Triage. In: Emergency Nursing Core
Curriculum (6th ed. 2007) at 28.
            ESI Handbook at 20.
            Id. at 2-3.

          Clinical differentiation of the etiology is obligatory, and is predicated upon triage policies

and procedures which identify “at-risk” patients who require immediate care.                Therefore, it is

generally recommended that:

                     All patients except those with obvious benign causes of chest pain are
                     transported as promptly as possible to the treatment area. The patient is
                     placed on the cardiac monitor, oxygen therapy is initiated and an intravenous
                     line is placed...If the patient is older than age 30 years, an electrocardiogram
                     (ECG) should be ordered and interpreted by the responsible physician

The overall goal of the emergency department is to identify these patients in a timely fashion so that

they can be rapidly evaluated and treated.              Delays in required diagnostic and therapeutic

interventions increase patient mortality.32

          In Joaquin Rivera’s circumstance, one extramural emergency medicine expert reviewer


                     All patients that present to the emergency department complaining of chest
                     pain require urgent triage. Once triage, unless the chest pain is clearly
                     determine not to be of a life-threatening nature, prompt evaluation in the
                     emergency department is indicated in order to identify the cause of the pain,
                     to mitigate deterioration, and to begin time-sensitive treatment.

          A second extramural emergency medicine expert noted:

                     The Standard of Care requires that individuals complaining of chest pain be
                     brought back immediately into the Emergency Department where
                     standardized protocols call for the patient to be placed on oxygen, an
                     intravenous line started, and the patient placed on a cardiac monitor. Within
                     a very few minutes, the patient should be seen by a physician. The Standard
                     of care calls for patients with chest pain of suspected cardiac origin to be
                     given oral aspirin, an intravenous beta blocker, anti-coagulation with some

               Id. at 184.
        Society for Chest Pain Centers, Process Measures (June 11, 2009). Accessed January
26, 2010 at

                 form of heparin, and treatment with some form of nitroglycerin. The failure
                 to treat Mr. Rivera as above was a deviation from the Standard of care.

       Delays in evaluation and treatment come at an exceedingly high price. These patients have

a high morbidity and mortality rate when significant delays in evaluation and treatment occur, related

both to clinical deterioration during the waiting process, as well as the time sensitivity inherent in

treatment strategies.33 The popular catch-phrase, “time is muscle,” is supported by clinical evidence

that the time to thrombolytic agent therapy 34 and other interventions designed to restore flow in the

coronary circulation is important in saving lives.35 A key objective of chest pain programs is to

reduce emergency department “door-to-treatment times” in appropriate circumstances.36

       The chest pain patient should have an electrocardiogram performed, and reviewed by a

physician, within ten (10) minutes of his or her arrival to the emergency department.37 For those

         National Heart Attack Alert Program Coordinating Committee, National Heart Attack
Alert Program Position Paper: Chest Pain Centers and Programs for the Evaluation of Acute
Cardiac Ischemia. Annals of Emergency Medicine, 35(5):462-71, 463. May 2000.
          So-called “clot buster,” fibrinolytic therapy, or reperfusion is a method of dissolving or
removing blood clots and coronary artery obstructions with the goal of restoring coronary arterial
circulation to heart muscle with is acutely deprived of blood flow, but still “alive” in the sense that
it can recover function if blood flow is timely restored. There is, therefore, a defined window-of-
opportunity. See Masoudi, F.A., Bonow, R.O., Brindis, R.G., Cannon, C.P. et al. ACC/AHA 2008
Statement in Performance Measurement and Reperfusion Therapy: A Report of the ACC/AHA Task
Force on Performance Measures (Work Group to Address the Challenges of Performance
Measurement and Reperfusion Therapy. Journal of the American College of Cardiology
52(24):2100-12. December 9, 2009.
         American College of Emergency Physicians Clinical Policies Committee, Clinical
Policy: Indications for Reperfusion Therapy in Emergency Department Patients with Suspected
Acute Myocardial Infarction. Annals of Emergency Medicine, 48(4)358-83, October 2006.
            Id. AEM 35(5) a 464.
        Phelan, M., et al. Improving Emergency Department Door-to-Electrocardiogram time
in ST Segment Elevated Myocardial Infarction. Critical pathways in Cardiology: A Journal of

patients who meet accepted criteria, and in whom there are no contraindications for therapy,

thrombolytic treatment should commence within 30 minutes of emergency department arrival.

Further, in patients who meet the criteria for angioplasty, cardiac catheterization and coronary artery

intervention should begin within 90 minutes of arrival to the emergency department.38

       In the case of Mr. Rivera’s care, there was a systematic and complete breakdown in protocols

and procedures. As stated by a physician-hospital administrator who reviewed this matter:

               1.      Mr. Rivera’s sudden death was the direct result of an undiagnosed
                       and untreated medical condition, most likely of an acute cardiac
                       nature, for which he appropriately presented to Aria’s ED. Contrary
                       to applicable EMTALA regulations and standard of care of hospital
                       emergency services, Aria failed to provide Mr. Rivera with a Medical
                       Screening Examination (MSE) and/ or Stabilize his Emergency
                       Medical Condition (EMC) after he presented to the ED with an EMC.
                       The basis for this opinion is the apparent failure of their hospital’s
                       EMC identification and triage process both initially upon presentation
                       and registration, and subsequently upon security camera and direct
                       visualization by ED personnel.

               2.      Complaints with Joint Commission standards reflect the applicable
                       standard of care for U.S. hospitals and is a condition of hospital
                       accreditation. Aria, though its leadership and administration likely
                       deviated from or failed to comply with the intent of at least the
                       Leadership, Human Services, Information Management, Patient Care
                       and Nursing standards. Irrespective of past JC Accreditation Survey
                       performance or accreditation status, examples of substandard
                       performance on November 28, 2009 in regard to the care of Mr.
                       Rivera were pervasive, blatant and directly responsible for Mr.
                       Rivera’s demise.

Evidence-Based Medicine, 8(3)119-121,September 2009.
         See, e.g., Antman, EM, et al. American College of Cardiology/American Heart Association
Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction 2004, accessed
at; see also National Heart Attack Alert Program Coordinating Committee, National
Heart Attack Alert Program Position Paper: Chest Pain Centers and Programs for the Evaluation of
Acute Cardiac Ischemia. Annals of Emergency Medicine, 35(5):462-71, 463. May 2000.

The intramural physician-lawyer reviewers and external consultants found a disastrous failure to

comply with institutional and medical standards of care across every parameter of Mr. Rivera’s

emergency department encounter: presentation, registration, triage, waiting room monitoring. These

opinions were substantially in accord with the DOH Report. See infra.


       The formulation, implementation, and enforcement of comprehensive policies and procedures

with respect to the triage of patients at the Frankford Hospital was manifestly lacking at the

Frankford Hospital on the evening of November 28, 2009, and directly contributed to the tragic and

preventable death of Joaquin Rivera. One extramural emergency medicine expert noted:

               Had Mr. Rivera been brought promptly back to the clinical area after his
               arrival, the standard of care would have connected him to an alarmed cardiac
               monitor, obtain a 12-lead electrocardiogram, place him on oxygen, start and
               intravenous line, and send appropriate blood work. The elctrocardiogram
               would in all likelihood have shown evidence of an acute coronary syndrome
               and should have promptly been interpreted by the physician leading to further
               evaluation and management.

               Has Mr. Rivera been treated in this manner, even if sudden cardiac death had
               occurred, it would have been identified early in its course allowing for
               prompt treatment including early defibrillation and initiation of CPR. There
               is compelling data that there is a greater than 90% chance of return of
               spontaneous circulation when sudden death is witnessed and defibrillation is
               performed within the first minute of identification of ventricular fibrillation.
               For every minute that this therapy is delayed, one loses 10% chance of
               survivability. By the time Mr. Rivera was found in the waiting room in
               asystole by the nurses, his chance for neurologically intact survival were lost.

       Corrective measure must be achieved. The critical nature of full compliance with well-

established and mandated standards of institutional, nursing, and medical care must include, at

bottom, a thorough and exhaustive “root cause” analysis. Simple, cosmetic solutions are not

appropriate. Building upon the DOH Report, and the extensive internal and external review process

performed in analyzing these events, the following recommendations are offered in the interests of

a constructive and continuing dialogue:

       #       The Frankford Hospital must ensure that appropriate policies, procedures, and

               protocols are in place to meet the full spectrum of patient needs. In particular, the

               registrars, who are at the vanguard of the interface between the public and Emergency

               Department care, must be trained to “red-flag” patients who present with high-risk

               complaints. This is best accomplished by training methods which place these high-

               risk complaints into the context of the real-life importance of down-stream medical

               care and intervention. Visual aids, wall charts, patient algorithms, and various other

               teaching and instructional aids and in-site reminders are recommended.

       #       There must be closer supervision of the registration desk staff and the registrars by

               trained nursing personnel. This contact is critical, a level of medical sophistication

               should be brought to the registration process. Access to high value medical care must

               not bottleneck or stall at the registration area.     Clearly, a backstop must be

               constructed to prevent patients with high-risk complaints and circumstances from

               being relegated to the waiting area when more urgent or emergent evaluation and

               treatment is required.

       #       There must be policies and procedures which acknowledge the dynamic nature of

               medical illness, particularly in the Emergency Department. Unlike an office practice

               setting or an outpatient clinic setting, where most patients become known over a

               period of visits and repeated contact, patients presenting for emergency department

               care are often unknown to the emergency department staff, and appear de novo,

    unannounced.      Accordingly, beyond vigilance at initial encounter, continued

    vigilance beyond the registration event is necessary to ensure the stability and well-

    being of those requested to wait for medical evaluation and care. The waiting room

    area must be surveyed for changes in patient status. Policies and procedures must

    incorporate some form of waiting area “sweep” by trained personnel to scan for

    patient deterioration.

#   The Emergency Department should have a process for repeating vital signs, and

    performing on-going assessments, of patients in the waiting room. There must be an

    acknowledgment that many medical conditions are neither readily apparent at

    presentation, nor static in nature.

#   Trained medical personal must maintain an awareness of all activities in the

    Emergency Department. The waiting room is an extension of the patient care area

    and the hospital, and it is, in many instances, the exclusive portal to medical care for

    some patients. While placing each and every patient in the waiting room on a

    monitoring device is neither practical nor feasible, there must be a process in place

    for observation of all patients in this area of the hospital. Patients in the waiting area

    are an extraordinarily vulnerable because, in general, there is no preexisting

    relationship with the Emergency Department medical providers.

#   There must be a system in place to account for those patients who do not respond to

    having their name called for further medical care. There can never be an assumption

    that the patient simply left the Emergency Department without being seen. When a

                patient fails to respond, then the identity and status of each patient in the waiting area

                must be ascertained.

        The death of Joaquin Rivera was a tragic event. Tragic in the loss of a loving husband,

father, and grandfather. Tragic in the loss of an esteemed and beloved member of the community.

Tragic in its manifest preventability. It is the sincerest hope of the Rivera family that this tragic and

senseless loss will give rise to better health care for the next person who presents to the Emergency

Department at the Aria Health Frankford Campus with cardiac symptoms.


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