All along, Joaquin Rivera's loved ones suspected that hospital staff screw-ups occurred on the night that the beloved musician died in the waiting room of Aria Health's Frankford campus.
Turns out they were right.
In a 22-page report released yesterday, the state Department of Health detailed numerous policy violations that took place on Nov. 28, when Rivera suffered a heart attack and sat dead for more than 40 minutes, unnoticed by hospital personnel.
Rivera, 63, entered the hospital's emergency department at 10:45 p.m. and complained of pain on his left side.
According to the report, surveillance footage showed that Rivera stopped moving at 10:56 p.m.
Seven minutes later, a hospital staffer told state investigators, she called Rivera's name and noticed that he was staring at a wall.
According to the state report, no hospital personnel checked to see if Rivera was in need of medical help.
The emergency department "triage nurse appeared at the patient waiting room door entrance and did not enter . . . between 10:45 p.m. and 11:47 p.m." to check on patient activity, the report shows.
Hospital staffers became aware of Rivera's condition only when another patient alerted them.
By that time, Rivera was already dead, and had been robbed by three vagrants who stole his wristwatch.
During subsequent interviews, state investigators found that hospital staffers were unaware of protocols that require them to check on patients in the waiting room.
"It was determined that the Director of Nursing Services failed to ensure that the nursing staff had knowledge of Emergency Department policies and procedures," according to the report.
In the same report yesterday, Aria Health officials detailed their response to investigations into Rivera's death.
The hospital suspended a triage nurse and registrar who offered conflicting accounts of what transpired in the waiting room that night.
According to the report, Aria officials also vowed to take a number of other actions, including: retraining staff on hospital policies; marking, with tape, a spot to where workers could walk to view the entire waiting room; maintaining a 24/7 security presence in the waiting room; and setting a definitive time frame for recalling patients.
State Health Department officials said that the hospital has until March 1 to implement all of its corrective actions or face fines.
City Council is due to hold hearings on the circumstances surrounding Rivera's death next month.