By Bob Aller

Posted December 2, 2024

A CMS Summary Statement Of Deficiencies of February 8, 2024 identified ER nurse understaffing that caused the horrific death of a 53-year-old father of four in the ER waiting room of Kaiser Permanente’s Vallejo Medical Center. Flagrant understaffing for years set the stage for an inevitable tragedy, according to Kaiser Vallejo ER nurses. 

Kaiser Vallejo ER nurses adamantly protested the understaffing of full-time nurses at their 52-bed ER. Many followed up their verbal notices of unsafe conditions by filing a form that documented the unsafe conditions, “Assignment Despite Objection.” The “ADO” form states: “As a patient advocate, in accordance with the California Nursing Practice Act… today’s assignment is unsafe and places my patients at risk. As a result, the facility is responsible for any adverse effects on patient care. I will under protest attempt to carry out the assignment to the best of my ability.”

The complaints cited unsafe conditions including: “unable to answer call lights, patients waiting too long for medication, state staffing ratio not met, no triage, nurse leaving patients to help others.”

Yet, even with an abundance of well-documented, verifiable incidents resulting from understaffing, administrators refused to correct the core ER understaffing. 

Ominous Conditions Awaited Patient Francisco Delgadilla-Machuca 

While at work on the afternoon of December 8, 2023, Francisco Delgadilla-Machuca, 53, suffered serious chest and back pains. Insured under a Kaiser health plan, he had a medical history of hypertension. Francisco knew he had to seek medical care right away. Leaving work early, he drove 30 miles to the Kaiser Vallejo ER, in the North Bay Region of the San Francisco area. 

Francisco Required Monitoring At Least Every Two Hours. No Monitoring Was Provided.

Francisco signed in at 3:45 PM. A triage was promptly conducted. Francisco described severe chest and back pains, symptoms that foreshadow a heart attack. His blood pressure was 170/85. His pain level was rated 7 out of 10. He was classified on the Emergency Severity Index (ESI) as a Priority 2. Francisco was at high risk for deterioration. 

Priority 2 requires monitoring at least every two hours. But in Kaiser’s Vallejo ER waiting room there would be absolutely no monitoring. In violation of a California healthcare regulation and CMS regulation 42.CFR.482.23 the Chief Nursing Executive did not provide adequate nurse staffing for monitoring patients in the waiting room. It was crowded with 30 to 40 patients. One nurse reported there was almost “standing room only.” Francisco Delgadilla- Machuca was sent to this waiting room. He immediately called his oldest son, Francisco Luz De Leon, who arrived quickly.

His son shared what he saw: “There were a lot of people in the waiting room; to be honest, none of them seemed like they were as distressed as my father was. He was holding tight on his shirt, where his heart was. He was struggling to sit on, uh, the chair. He kept moving around. He was lying down on the floor.”

Francisco’s son asked the ER clerk when his father would receive care. The clerk said there were 28 patients ahead of him. He called a brother, who quickly arrived with his mother and other brothers. As the family saw Francisco getting worse, they witnessed other folks taken immediately into the ER for treatment.

Family Went Outside ER To Call 911

Just after 5 pm, Francisco suffered excruciating pain. At 5:14 PM, a family member hurried outside the ER to call 911. A fire engine arrived in 6 minutes. The lead EMT explained to the family and to Francisco who was in a wheelchair that the fire department did not have the authority to take Francisco elsewhere from the Kaiser ER. News reports stated the lead EMT went inside the ER and spoke to the admitting clerk. Francisco was then taken into the ER. His pain level was rated a 10. Kaiser’s pain chart shows level 10 is the “worst pain possible.”

Even with the “worst pain possible,” Francisco, a patient in an extremely severe medical crisis, was abandoned. He was not seen by a Kaiser doctor. Instead, he was returned to the unmonitored waiting room to suffer in agony for 6 more hours, until his death.

Francisco Collapsed Onto Floor 

At about 11:30 p.m., Francisco’s son spoke to the new clerk who just came on duty. He learned his father was number 5 in line. “We were all glad, relieved,” he said. But it was too late. “I saw my father just collapse. I ran out to him, trying to support him. I heard his last breath go out.”

Francisco’s wife, Maria, recalled that terrible moment:  “I turned around, and that’s when my husband fell to his knees and went out on the floor. He was just five numbers away from his turn. I went crazy yelling at all the doctors, kicking the trash cans, and throwing water bottles.”

Francisco lay collapsed on the floor, surrounded by his family. He was finally seen by Dr. Nisha Chauhan. Attempts at resuscitation were futile. Dr. Chauhan pronounced Francisco dead at 11:59 PM. 

Autopsy Reveals Ruptured Thoracic Aortic Aneurysm

The family requested several hours to grieve. Soon after 3:30 AM on December 9th, Francisco’s remains were transported to the county morgue. On the morning of December 11th an autopsy was conducted by a forensic pathologist at the Solano County Coroner’s office.

The findings documented a medical horror story. Francisco Delgadilla-Machuca died from a ruptured thoracic aortic aneurysm (TAA). He bled out. This event is considered extremely painful, like a “severe, tearing pain in the chest or upper back.” The tearing can be all at once, or it can extend over time as three layers of tissue tear. With the rupture, blood pressure finally falls precipitously, leading to a state of shock.

Without prompt surgical intervention, death almost always results. Francisco’s four sons and wife watched him die in the Kaiser ER waiting room. 

California Nurses Association Union Rep Raquel Benito: “Long Waits Were Common”

After the CMS deficiency summary was released, NBC investigative reporter Hilda Gutierrez reported on the case.

She interviewed Raquel Benito, RN, the California Nurses Association representative for Kaiser Vallejo ER nurses. Ms. Benito provided key details:

An 8-12 hour wait for patients was not unusual.

The ER was operating with 6 nurses, or less than half of the 14 nurses needed.

For years, understaffing was an issue.

Management had continuously ignored complaints to rectify inadequate staffing.

A review of YELP posts over a period of years revealed an abundance of angry patient posts about overly-lengthy waits in the ER. The staffing issue at this ER was a matter of public record.

Nurses Met With Management, But A Request For Additional Staffing Was Rejected

Other ER nurses were interviewed by reporter Gutierrez. She reported that a month prior to this tragic fatality the nurses met with management to request additional nurse staffing. But recalcitrant administrators rejected the ER nurses pleas.  

Just Two Years Earlier ER Was Cited By CMS For Understaffing 

Back in 2021, it appears a whistle-blower from Emergency Medical Services filed a confidential complaint about the Kaiser Vallejo ER. The complaint triggered another CMS Summary Statement of Deficiencies. The summary included multiple Kaiser ER staff reporting persistent understaffing.

CMS Revealed Kaiser Vallejo ER Failed To Provide Timely Triages

This CMS report found the Kaiser Vallejo ER violated EMTALA by failing to provide timely triages. Understaffing caused seriously delayed triages.

The CMS 2021 deficiency report indicated when ambulances brought patients in crisis to the ER, the EMS staff was required to stand by the gurney for lengthy periods. A lack of adequate staffing left the ER was incapable of promptly triaging patients. According to CMS, the patients were left for their conditions to worsen. Yet, in response, Kaiser did not increase core staffing.

CMS Reported Kaiser Interferred With & Slowed Down 911 Services

The report described four cases where ambulances waited over an hour before the patients were seen. The ambulance crews could not leave until their patients were admitted. Thus, the Kaiser Vallejo ER caused improper delays in the community’s 911 medical response times. Those delays would have adversely impacted patients waiting for an ambulance after suffering from heart attacks, strokes, other critical conditions or accidents.

3 Days Before Francisco’s Death ER Nurses Posted A Petition Seeking Safe Staffing. But Administrators Disregarded This Public Plea!

ER Policies Disregarded By Administrators

CMS found Kaiser administrators disregarded its ER policies: “All patients will receive care that is safely focused, minimizing risk, and preventing harm.” “Staffing needs are assessed continuously and are based on operational need.”

ER Physician Gordon Chew: “Bad Things Could Happen!”

During the CMS investigation of Francisco’s death, Kaiser Vallejo ER Physician Gordon Chew admitted to investigators that low staffing and the failure to escalate the issues resulted in Francisco’s death. He said ESI Level 2 patients (Francisco) should have been reassessed every two hours. But the physician’s testimony also suggests this may not have been the only time a preventable tragic event occurred here. His remark was ominous: “If nursing was short-staffed and the emergency room was full, bad things could happen!” 

Chief Of Medicine’s Explantation For No Monitoring 

According to the CMS report, the Chief of Medicine, (Dr. Christopher Walker), informed CMS investigators that the waiting room nurse was pulled into the ER to help since the ER was full. The waiting room nurse was called “Nurse First.” That nurse’s job was to reassess all triaged patients in the waiting room. With no “Nurse First,” the triage nurse was supposed to take her place. But the triage nurse was continually busy. Thus, reassessments and monitoring were impossible. This understaffing constituted a violation of state and federal regulations.

Director Of Nursing Services Violated 42 CFR 482.23

According to CMS, the Director of Nursing Services (Chief Nursing Executive) duties include providing an adequate number of nursing personnel to make the Vallejo ER safe. 42 CFR 482.23: “…He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. According to CMS,“The Director of Nursing Services must provide for the adequate supervision and evaluation of all nursing personnel. This standard was not met.” Some may consider the Chief Nursing Executive’s failure to correct ER understaffing was an act of negligent homicide as defined by California Penal Code 192(b) PC. In California, negligent homicide refers to a situation where someone’s negligent actions result in the death of another.

• Negligent homicide involves actions that do not involve the malicious intent to kill. In this case, Kaiser ER nursing staff gave ample notice of perilous understaffing. There was no ER nursing staff in the waiting room to monitor patients with potentially fatal conditions.

CEO Denies Staffing Was A Problem

…”staffing had never been an issue… complaints of short staffing were from a bad night they [nurses] experienced.”

On January 10, 2024, a month after Francisco’s death, the CEO spoke to  investigators for CMS. The CEO had 4 weeks to be briefed on the facts of the case by his staff. The CEO was interviewed briefly by investigators. The report includes quotes from the CEO. “He stated staffing had never been an issue.” In addition, “He stated he spoke with staff and usually the complaints of short staffing were from a bad night they [nurses] experienced.” Yet, in formal written complaints, the Kaiser Vallejo ER nurses repeatedly reported staffing was a serious issue. In addition, the CMS Summary Statement of Deficiencies ruled that staffing was an issue. “There was not enough emergency room staff to provide effective emergency care when patients were not assessed and monitored.”

The CEO’s statement that “staffing had never been an issue” does not appear to be accurate or truthful.

In 2023, Mr. Adams’ compensation was listed at $17,268,060.

Patient safety may not have been one of his top priorities.

The Question: Who Is Responsible? The Answer: Kaiser’s Governing Body Members! 

Under federal regulations, Kaiser’s Governing Body members bear responsibility for what  happened at Kaiser’s Vallejo ER. The CMS report states the Governing Body [members] failed to fulfill their legal responsibilities. The CEO, Greg Adams, serves on the Body. The Governing Body was cited for failing to provide adequate staff. CMS also cited the Governing Body for failing to provide a diversion plan for a patient surge during a staffing shortage. 

Three Physicians On The Governing Board Failed To Provide Effective Oversight

The Kaiser Governing Body includes three physician-members. Richard Shannon, MD, is the Chief Medical Officer for the Duke University Health System. Regina Benjamin, MD, served as the 18th Surgeon General of the United States. A. Eugene Washingon, MD, is Chancellor Emeritus at Duke University. According to CMS, these and other members of the Governing Body failed to perform effective legally required oversight.  

Governing Board Heavily Weighted For Financial Rather Than Clinical Oversight

Ten of the thirteen Governing Body members have a business or legal background. Thus, the Governing Body is heavily weighted for business planning and financial oversight, rather than oversight of Kaiser’s mission to provide “high-quality” health care services. However, the Governing Body apparently provided exemplary financial oversight. 

Kaiser Profits: $4.1 Billion In 2023! 

Top Row: Greg Adams, Ramon Baez, David Barger, Regina Benjamin, MD, Jeff Epstein, Leslie Heisz. Bottom Row: David Hoffmeister, Judith Johansen, JD, Jenny Ming, Matthew Ryan, Richard Shannon, MD, Vivek Sharma. (A. Eugene Washington, MD, was mistakenly left off the image above.)

Watch for Part II of this report.

Watch for a coming story at another Kaiser ER with inadequate nursing staff, leading to another fatality!

Hospital Watchdog welcomes comments and suggestions.