Edgerton Hospital staff, in responding to a patient's and a nurse's cardiac arrests on the same morning, left two other patients alone in the emergency room, according to an inspection report.
The hospital was given 22 state and federal citations for problems related to the Aug. 9 events, including not having enough staff.
Five of the federal citations were serious enough to warrant a determination of "immediate jeopardy," the most serious category of violation.
The patient with cardiac arrest died the same day, though it's not clear why; the ER patients are not known to have been harmed. The report doesn't say what happened to the nurse, and state and hospital officials wouldn't tell the State Journal, citing privacy laws.
The state inspection, conducted from Sept. 26 to Oct. 2, was prompted by an anonymous complaint. The resulting citations are for problems such as inadequate staffing, lack of CPR training and failure to document how the hospital contacts on-call staff or EMS services for assistance.
"There is no hospital record indicating phone calls were made to extra staff to report in to help with the codes," according to the Oct. 2 report from the state Department of Health Services.
Yet the hospital did contact additional staff and several came in, Caryn Oleston, the hospital's vice president for patient care, told the State Journal.
An off-duty employee who is also a family member of one of the ER patients remained in the ER, so the patients really weren't alone, Oleston said. Those patients were not harmed, and the first patient's death was not related to the staff's response, she said.
"It's all about triage," Oleston said. "You send your resources to the patients who need them the very most."
The hospital has increased staffing, trained more people in CPR and expanded its on-call system, she said.
The state accepted the hospital's plan of correction after a follow-up visit Nov. 19, health department spokeswoman Claire Smith said. Two additional citations were issued, however, for some inadequate medical records. No fines were imposed.
According to the inspection report:
The first patient, who developed pneumonia while in the hospital, went into cardiac and respiratory arrest about 3:30 a.m.
Those responding included the nurse, who collapsed about 15 minutes later while walking around the foot of the patient's bed.
A licensed practical nurse in the ER had already left to help the patient. After the nurse collapsed, a registered nurse in the ER left to help her, leaving the ER patients without any hospital personnel.
The ER patients included one with a head injury and one with a suspected urine infection.
The patient who had suffered the cardiac and respiratory arrest died shortly afterward.
Many of the 10 state violations and 12 federal violations are for the same things.
An annual average of three immediate jeopardy determinations have been issued for all Wisconsin hospitals combined the past five years, Smith said. Nine have been issued so far this year.