By Josh Brokaw
The death of a patient who was awaiting care at Cayuga Medical Center’s emergency department is under state investigation.
The New York State Department of Health confirmed on Friday, Feb. 3, that it is investigating a patient death on Jan. 19 in the emergency department waiting room at CMC. 
Requests for comment to Cayuga Medical Center leadership have so far been ignored. This story will be updated with any comment that CMC administrators would like to share with the public.
The nurse who is apparently being held responsible by CMC administration for the patient’s death told her story to Truthsayers over the phone last week. She requested that her name be withheld, so let’s call her Roberta. Roberta, according to herself and two other emergency department [ED] staff nurses, is a travel nurse who had worked in the CMC ED since June 2016 on short-term contracts. Roberta was a staff nurse in the Rochester General Hospital emergency department for more than 10 years before becoming a travel nurse, and says she has her certified emergency nurse [CEN] credentials.
Roberta was working in triage on the night of Jan. 19, which is a position in the ED that requires that the nurse sort “injured and ill patients into categories of acuity and prioritization based on the urgency of their medical or psychological needs,” according to the CMC ED triage policy. In other words, the triage nurse decides who most urgently needs medical attention and is responsible, under CMC policy, for monitoring patients in the ED waiting room.
Truthsayers will take a closer look at current problems with CMC triage policy and practice later in the week. Roberta said that she was never shown the CMC triage policy before the events of Jan. 19 and never received a “one to one” orientation from another nurse on triage practices. For example, she said she only learned after the patient’s death that, per policy, the triage nurse is supposed to “make a round” of a busy waiting room to take vital signs every hour.
The following is Roberta’s account of what happened on the evening of Jan. 19. Text in direct quotes are Roberta’s words; everything outside those quotes is my characterization of our conversation with additional details in parenthesis:
The patient, a man in his 50s, was brought by paramedics to the ED from a West End convenience store, where a worker found him on the floor, asleep but responsive.
“EMS went to the scene twice. The store called the first time, he was supposed to mosey on his way. I guess he didn’t, then the store called the police department, the police department called EMS back and somehow this guy finally agreed to go to the hospital.”
[The Ithaca Police Department activity log for Jan. 19 shows a call to the store at 5:43 p.m.]
The patient was refusing care en route from the store to the hospital.
“We had no history on this guy, we had nothing. The policy states EMS is supposed to take the patient to the charge nurse and the charge nurse determines where he goes. The charge took the phone report and gave the go ahead to put him in the waiting room without putting eyes on him.”
Roberta said the patient refused her first attempt to take his vital signs, when he was first brought in around 6 p.m. “We were keeping eyes on him.” There were about 12 patients in the waiting room at the time, she said.
“There was nothing obviously wrong with him. His breathing was normal, nothing obvious … That’s the part I keep beating myself up about. Did I miss something? It keeps playing over and over and over in my head. What did we miss? What did I miss? He wasn’t complaining of chest pain, so there was no reason to get a EKG … He literally appeared stable. His color wasn’t off. When [the receptionist] told me ‘I think that guy is dead over there,’ the one thing I noticed right away is there was a color change. What he looked like when he first came in to when she said that to me …”
The patient allowed Roberta to check his vital signs sometime between 6:45 p.m. and 7 p.m.
“He wasn’t somebody who was making a lot of noise, he was just kind of hanging out there … I went over and asked him a couple basic questions – basically asking if he was having any pain, if he was lightheaded or dizzy. Basic, simple, yes no questions. He wasn’t having any pain, he didn’t know why he was there and wanted to go home.”
An “acutely ill patient” came into the ED with shortness of breath around 8 p.m., and Roberta said she took that patient back to an open room inside the ED.
“When I took him to the back that left pretty much nobody but registration staff up front, to keep an eye on a waiting room of 10 to 15 people. I came back, the registration clerk said ‘That man looks like he’s dead.’ I went over, checked him for a pulse and rushed him to the back.”
Resuscitation did no good: the man was declared dead around 8:30 p.m. on Jan. 19.
The next day, a Friday, Roberta said she was called “into the office” by administrators and “asked for the chain of events” from Jan. 19. She was then put “right back in triage” and held that position through another busy day with numerous people in the waiting room.
“Around 5:30, 6 o’clock, [p.m.] they turned around and they suspended me until the investigation was over. First, it was the timeline didn’t match. Then it came down to the camera never saw me encounter the patient. I don’t know what’s wrong with the camera – I have a moral obligation to encounter the patient. Whether it’s the EMT or Grandma Etna brings them in and gives the report it’s still your responsibility to see the patient …”
The following Monday [Jan. 23], Roberta’s travel nurse agency called her to say that CMC was terminating her contract “based on falsifying documentation.” The claim CMC made, Roberta said, was that she back-timed the record of when she took the patient’s vital signs. She cited two problems with this reasoning: first, that CMC practice is to always back-time the record of when vitals were taken to within 10 minutes of a patient’s arrival. The second problem Roberta cited is that the patient refused her taking his vital signs at first: “Per our triage, the way the computer system is set up you have to get vital signs on a patient … or you can’t complete triage. You can’t go in there and put all zeros.”
On Tuesday [Jan.24], Roberta’s agency was told CMC was going to set up a meeting with her, and she retained an attorney. The next day, Wednesday, she met with the attorney in the morning in anticipation of a meeting with CMC in the afternoon. While her attorney waited to hear from CMC administration whether he would be permitted to attend the meeting, Roberta waited and the meeting was eventually called off. Since that day, Jan. 25, Roberta said that as of Feb. 5 she had heard nothing from CMC. She continues to work at another per diem nursing job.
“There was minimal resources,” Roberta said of the CMC ED on Jan. 19. “It’s a system that needs to be fixed. The lack of resources really showed … I’m somebody who thinks I can do everything by myself, and apparently I can’t.”
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 In response to a request for comment sent to the New York State Department of Health press email, I received this response from an unnamed employee last Friday and was asked to “attribute to the Department of Health.”
The Department of Health takes the health and safety of hospital patients very seriously. The Department is investigating the death of a patient at Cayuga Medical Center and will take appropriate action based upon the results of the investigation. Because the investigating is ongoing, the Department cannot comment further.
 A call for comment to John Turner, CMC vice president of public relations, was made on Tuesday, Jan. 31, with no response. This reporter sent a follow-up email to Turner last Friday evening, with the entire CMC senior leadership staff and several board members listed at this link carbon copied, informing them the Department of Health had confirmed the investigation and that Truthsayers would be publishing this report come Monday. By first publication on Monday, Feb.6, no response had been received from CMC leadership.