Medicare regulators confirm woman coded in ER waiting room after waiting 5+ hours for care

WILMINGTON, N.C. (WECT) - Two months after reports surfaced that a woman had died in the Emergency Department waiting room at Novant Health New Hanover Regional Medical Center after waiting for hours to be seen, federal regulators have released a report that appears to confirm that’s essentially what happened. NHRMC initially downplayed the media reports on this patient’s death, saying no one died in their Emergency Room lobby and no state inspectors had been at the 17th street campus to investigate the death.

That report was published on June 16. While WECT has no confirmation that state inspectors had been on campus at the time of publication, the station now knows that inspectors from the Department of Health and Human Services (DHHS) were on the hospital campus looking into these claims less than a week after our report aired.

According to a report released to WECT Tuesday afternoon by the Centers for Medicare and Medicaid Services (CMS), inspectors were at the Wilmington hospital from June 21 - 29, investigating complaints about the elderly woman’s death and other issues. It was that inspection that prompted federal regulators to notify NHRMC officials that their Medicare contract would be terminated on August 12.

Here is an excerpt from the just-released report from DHHS:

“The findings of the investigation revealed a 77 year old female (Patient #7) presented to the facility’s emergency department on 06/06/2022 at 2031 for complaints of vomiting, weakness, unable to stand, fever at home and had a history of rectal cancer receiving chemotherapy. Triage vital signs revealed a Blood Pressure 87/53, Heart rate 67, Respiratory Rate 30, Temperature 98.4 at 2043. Findings revealed Patient #7 was as triaged ESI (Emergency Severity Level Index) 3 (Urgent). Repeat Blood Pressure at 2106 118/55. Patient #7 was placed in the emergency department waiting room. Findings revealed Patient #7 was not reassessed per facility triage policy. Findings revealed the next documental entry in Patient #7′s medical record was on 06/07/2022 at 0200 (4 hours 54 minutes after the last blood pressure and 5 hours and 29 minutes after arrival). Code Blue Spiritual Care and Provider were at bedside at 0204. Patient #7 was pronounced deceased at 0425 on 06/07/2022 after discussion with family to withdraw life support measures.”

In June, hospital officials had indicated on background that the patient coded in the waiting room, but they were able to reestablish a pulse after that happened. So her time of death was not pronounced until after she’d been seen by a provider, but the initial story shared with WECT, that she went into distress that ultimately proved fatal while still waiting for care in the lobby, appears to be true according to the DHHS report.

Further excerpts from the report include interviews with an EMT and MD at the hospital on June 6th, the night the patient coded:

“Interview on 06/23/2022 at 1510 with EMT (Emergency Medical Technician) #36 revealed she recalled Patient #7 family member asking for help in the waiting room. Interview revealed Patient #7′s husband was trying to wake her up and she was not responding. Interview revealed EMT #36 responded to assist and Patient #7 was unresponsive to pain with agonal respirations. Interview revealed she rolled her back to try and get vital sign and possibly got a heart rate of 29. Interview further revealed other staff went to get help as she took Patient #7 to Intake 6 where ED MD #37 arrived at same time and Code Blue was called.”

“Interview on 06/23/2022 at 0920 with ED MD #37 revealed he recalled Patient #7. Interview revealed he was asked to see an unconscious patient. Interview reveled he arrived to Intake 6 at the same time as the nursing staff with the patient. Interview revealed Patient #7 was unresponsive and pulseless upon his initial assessment. Interview revealed the nursing staff told him Patient #7 had a pulse. Interview revealed he never found a pulse on his assessment until after the Code Blue and CPR efforts began.”

After CMS threatened to terminate NHRMC’s Medicare contract following their June inspection and interviews, the hospital began a hiring spree. They brought on hundreds of nurses since the point in time when their nursing shortage was at its height. We’re told that at one point, the hospital was short 400 nurses. They’ve now brought that number down to about 100, and state inspectors who came back to the 17th Street campus for a reinspection on August 11 (a day before the Medicare contract was set to be terminated), have recommended that the hospital be returned to good standing with CMS.

Whether CMS will accept that recommendation remains to be seen.

“We are currently reviewing the revisit findings and do not have a set date for the review to be completed. More information will be available once that review is complete,” a spokesperson for the federal agency told WECT on Tuesday.

A Novant Health Spokesperson issued the following statement in response to the release of the survey:

“We’re disappointed that patients experiencing delayed care led to the CMS survey on June 21. We respect and value the review process and the additional insight it provides, and we’re glad that following our August 8 reinspection, CMS found we were in compliance with Medicare guidelines. It’s been a challenging few months at the hospital and we’ve been working diligently to improve and recruit additional clinical staff. Thanks to those efforts by our dedicated team members, wait times have decreased, more beds have reopened, and our clinical teams are getting more members every week.”

This is a developing story. Reporters are still reviewing the rest of the 95-page report on inspectors findings at NHRMC that prompted them to put the hospital in “Immediate Jeopardy” because of concerns about patient safety. Check back for additional details.

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