Two weeks after the patients death on Sept. 13, state health inspectors arrived at the hospital, owned by for-profit Steward Health Care, to investigate. During their review of patient records, they found an emergency department with recurring staffing problems that at times seemed to be in near-meltdown.

Extremely sick patients had no assigned nurses, including one patient who was previously found unresponsive in a hallway. In another instance, an overworked nurse who was extremely busy and was behind, trying to catch up left a patient who had been vomiting in the waiting room for more than 10 hours. A friend discovered the patient barely conscious; the person was intubated and admitted to the intensive care unit, according to a state inspection report. It is unclear from the report if those patients survived, and hospital officials declined to provide that information.

State and federal officials declared the safety lapses put patients in immediate jeopardy, a severe sanction that required Good Samaritan to develop a plan within 23 days to fix its emergency department or risk losing its Medicare funding. Good Samaritan executives said they addressed the problems immediately, including bringing in more staff.

The hazards in the hospitals emergency department should not have been a surprise to state and federal regulators. Inspectors for the Massachusetts Department of Public Health had found serious patient safety violations in Good Samaritans emergency department three other times since 2021, documents obtained by the Globe show. After each inspection, investigators required the hospital to produce an improvement plan, but their visits resulted in little lasting change.

It wasnt until Jan. 31, when the seriousness of the financial crisis engulfing the company had become public, that the health department began sending daily monitors to Good Samaritan and other Steward hospitals, raising concerns about why the state didnt do more sooner.

While emergency departments are under strain across Massachusetts and the country, staff at Good Samaritan have been especially overwhelmed as they try to treat thousands of additional patients after two nearby hospitals shut their doors. At the same time, nurses have told state inspectors that private equity-backed Steward has neglected to hire enough staff and buy enough supplies.

The Massachusetts Nurses Association, the union that represents nurses at the hospital, warned state and federal health officials in 2021 and 2022 about the deterioration of the emergency department. Among the problems they cited: the potentially avoidable deaths of two patients, patients without nurses, patients being left in the waiting room for hours without being reevaluated, and managements failure to follow through on its promises, according to a letter and a memo obtained by the Globe.

Last March, emergency room nurses spoke directly to Governor Maura Healey, Lieutenant Governor Kim Driscoll, and Secretary of Health and Human Services Kate Walsh about their concerns when Massachusetts officials visited Good Samaritan after a fire shut down nearby Brockton Hospital.

In September, on the day the patient died while in the registration line, 19 nurses were supposed to be on duty, according to an internal staffing report. There were eight.

Dr. Robbie Goldstein, commissioner of the state Department of Public Health, said the patients death was a tragic event and for all us it really gave us significant pause. But he said inspectors have provided close oversight of the Good Samaritan emergency department since 2021; the department thoroughly investigated every complaint, required an improvement plan, and revisited the hospital once after each plan was submitted to ensure its implementation, he told the Globe.

He acknowledged the department did not send in regular monitors until two weeks ago, but said that step has traditionally been taken only during nursing strikes.

Do I think that we will change the way that we provide oversight, evaluate facilities, and intervene at times of financial distress? Absolutely. That story is being written right now, Goldstein said.

He said he recognizes the situation at Good Samaritan and other Steward hospitals is hard for patients and Steward staff. We are working 24/7 with Steward and with the rest of health care to make sure that we can address the challenges that people are facing, he added.

The inspections of Good Samaritan were conducted by state officials on behalf of the US Centers for Medicare and Medicaid Services, which issues reports called statements of deficiencies when it finds problems. Those reports include descriptions of incidents but not patients names or other identifying details.

In a statement emailed to the Globe, Good Samaritan president Matt Hesketh said that after the immediate jeopardy findings on Sept. 26 and 28, the hospital immediately hired technicians to help assess the vital signs of patients in the waiting room, and deployed nurse practitioners and physician assistants to help triage walk-in patients steps that were part of the improvement plan. The hospital also is offering $40,000 signing bonuses to nurses hired to work in the emergency department.

Inspectors from the Centers for Medicare and Medicaid Services recently visited the hospital and we remain in full compliance with all guidelines and protocols, Hesketh said.

We have faced unprecedented challenges over the past few years, however, the safety of our patients and providing excellent, compassionate care is our focus day in and day out, he added.

Goldstein, however, said that monitors stationed at Good Samaritan and other Steward hospitals have received additional complaints about patient care, and that the department is investigating the allegations. He did not describe the nature of them.

Experts in emergency medicine and patient safety consulted by the Globe could not assess whether the issues at Good Samaritan were more severe than elsewhere.

Theres a lot of bad things there, said Dr. Joseph C. Tennyson, president of the Massachusetts College of Emergency Physicians, an advocacy group for doctors, after being told of the reports. But he added, Bad things like this are happening everywhere right now because the capacity doesnt exist.

Just two weeks ago, the state Department of Public Health designated hospitals in Greater Boston and north of the city as Tier 3, meaning they have a high risk of capacity problems throughout their hospitals and need to meet more frequently with health officials and one another to coordinate patient load. Good Samaritan and other hospitals south of Boston have been in Tier 3 for the past year, after Brockton Hospital closed.

Patients have suffered because of delays at other hospitals. A disabled patient became unresponsive in the emergency department waiting room at Cooley Dickinson Hospital in Northampton in November 2022, during a six-hour wait for care. He died several hours later.

The patient, a 74-year-old man, checked in about 8:30 p.m. complaining of a cough and other respiratory symptoms. The triage nurse ordered lab tests and a chest X-ray and sent him to the waiting room, but failed to measure his blood oxygen level, according to a state inspection report. Another nurse told inspectors the triage nurse was running behind and there were too many patients waiting to be triaged. When his guardian the man was disabled, according to a relative told staff he did not look well, they found him unresponsive. Death records show he had the flu and pneumonia, and died of sepsis.

Laura Oggeri, a spokesperson for Mass General Brigham, which owns Cooley Dickinson, said that she could not discuss a specific case due to patient confidentiality rules, but that the hospital now requires mandatory additional medical reassessments for those waiting for care.

While many emergency departments are struggling with severe overcrowding amid a national shortage of nurses, they differ in how effectively they respond, said Barbara Fain, executive director of the Betsy Lehman Center for Patient Safety, a Massachusetts state agency.

We do know that there is wide variability in the safety cultures of different hospitals, and that is really driven by the leadership, she said.

Dr. Zirui Song, associate professor of health care policy and medicine at Harvard Medical School, said the circumstances at Good Samaritan might be attributable to staffing reductions. A study he and others published in December found that after hospitals are acquired by a private equity company, they experience a 25 percent increase in adverse events, such as infections and falls. This is happening even as other hospitals are seeing a decline in such events, he said.

One of the primary hypotheses that we have is that staffing reductions after a private equity acquisition might explain these findings, Song said, and that might apply as well to the emergency department.

Song, an internist at Massachusetts General Hospital, called what happened to patients at Good Samaritan gut-wrenching and heart-breaking and not something he would expect to see at Mass. General, even when the emergency department is extremely busy. Patients with chest pain and shortness of breath are typically worked up fairly rapidly, he said.

So the fact the E.D. is full does not mean that these adverse events . . . are acceptable or expected, he said.

But sometimes they are unavoidable, said Tennyson, the emergency physicians group president. As an emergency department physician, he said, he has seen patients designated ESI 2 the second most severe level of patient illness who have waited 14 hours or longer. Ideally a patient with chest pain would be seen right away and get an electrocardiogram, a recording of the hearts electrical activity that can help diagnose a heart attack, within 10 minutes, said Tennyson, who is chief of emergency medicine at UMass Memorial HealthAlliance-Clinton Hospital.

But its not uncommon for a chest pain patient to have to wait in a busy ER, because there are five or six people or more that are having chest pain, and most of them are not having a heart attack, Tennyson said.

Those situations are painful and demoralizing for the staff, he said.

To see somebody in the waiting room that you absolutely know you need to go see, that you need to get seen right away, and theres no way to do it thats injurious and its contributing to burnout, he said.

Liz Kowalczyk can be reached at lizbeth.kowalczyk@globe.com. Felice J. Freyer can be reached at felice.freyer@globe.com. Follow her @felicejfreyer.

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