Twice, when an emergency-room nurse called out the name of Joaquin Rivera and he did not respond, she had no idea he'd already suffered a massive heart attack.
The reason: The nurse did not venture beyond the waiting-room doorway and simply did not see him where he sat, unattended, for nearly an hour.
That was among the findings made public yesterday after a state investigation into the treatment of Rivera, a 63-year-old guidance counselor who died Nov. 28 at Aria Health's Frankford campus. Thieves stole his wristwatch as he sat unresponsive in the waiting room.
The 113-bed facility, at Frankford Avenue and Wakeling Street, formerly known as Frankford Hospital, already has taken measures to retrain staff and beef up security. In a plan of correction released yesterday, the hospital said it also had suspended an admissions clerk and a nurse. It was unclear, however, whether it was the nurse who failed to check on Rivera in the waiting room.
According to a state review of a surveillance video, that nurse simply did not look in his direction, possibly because a pillar obstructed her view, said Stacy Mitchell, deputy secretary for quality assurance at the Pennsylvania Department of Health.
"You can't just stand in a doorway and call a name and hope that everybody out there's OK," Mitchell said.
Elsewhere in the 22-page report, an account from the unnamed triage nurse appears to dispute the assertion that she did not look for Rivera, but Mitchell said the video supported the state's finding.
In its correction plan, Aria Health said the suspensions had been meted out because the two employees' accounts conflicted in some way with what could be seen on the video.
Rivera, a North Philadelphia resident and popular musician who worked as a school counselor, walked into the emergency room at 10:45 p.m. and complained of pain on his left side. He appeared to suffer the heart attack at 10:56, according to the state's review of the video.
The triage nurse called his name for the first time at 11:03 - 18 minutes after he came in. He was finally examined at 11:47 p.m., after the watch was stolen and another person in the waiting room summoned help. According to the state report, several emergency-room employees said they were unaware of a hospital policy that required checking on waiting-room patients.
Mitchell said there was no way to know whether faster action might have saved Rivera's life.
"Obviously, trying to save someone sooner is better than trying to save someone later," the state official said.
Rivera's son, Joaquin Jr., did not respond to a request for comment. Lawyer Thomas R. Kline, who is representing the family, said the state report documented "a total, systemic breakdown of the delivery of emergency care."
Asked about the findings, the hospital responded with an e-mail that listed a number of corrective measures that are under way.
Among them: Security has been increased by more than 30 percent, with added staff and hours of coverage. And a new orientation program was created for registration staff, with an emphasis on communication with nurses.
"Since Mr. Rivera's death, Aria has taken a number of proactive steps to ensure that nothing like this ever happens again," the hospital said.
The hospital also said it had instituted a policy of calling patient names every 10 minutes if they don't answer at first. And it has identified a location on the waiting-room floor from which all parts of the room can be seen, marking it with tape so that triage nurses know where to stand when calling out names. An architectural firm has been hired to see if further improvements can be made.
Visibility was also a problem for the admissions clerk, or registrar, State Rep. Tony Payton Jr. said. The window that separates the registrar's desk from the waiting room was partly obstructed by notes stuck to the glass, he said.
Another problem lay in how the registrar reacted to Rivera's description of his symptoms of left-side pain, said Payton, a Democrat who represents the district where the hospital is.
In an older man, those symptoms could signify heart trouble, medical experts say, but the intake personnel did not ask additional questions. From now on, Payton said, the hospital has agreed that they will.
"The intake people are now required to ask probing questions when they have those sorts of reports," he said.
The state did not impose any penalties on the hospital, but it faces fines if it does not implement the plan of correction by March 1, Mitchell said.