MILWAUKEE – The night Tashonna Ward died, Froedtert Hospital staff didn't check her vital signs as often as they should have after she arrived at the ER with chest pain and shortness of breath, federal documents show.

Ward, a 25-year-old day care teacher, spent more than two hours waiting to see a doctor at Froedtert on Jan. 2.

She left to find quicker care, then collapsed and died just over an hour after leaving the ER.

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And Ward wasn’t the only ER patient who didn’t receive the care she was supposed to.

After her death, a federal inspection of Froedtert found ER staff failed to check on multiple patients as often as they should under hospital policy during the months of December and January. At least one nurse acknowledged the staff had run late, according to the inspection obtained by the Milwaukee Journal Sentinel through an open records request.

Inspectors found the staff was late checking the vital signs of Ward and six other patients, out of the 20 patient records they reviewed. The inspection report doesn't note how the delays affected these patients.

Among the cases was a patient who had taken a painkiller and alcohol in a suicide attempt. The patient's vital signs were supposed to be checked every 30 minutes but were not checked over a five-hour period, according to the report.

Some records were missing, inspectors found. In December, a patient left the hospital without getting a recommended blood transfusion. There’s no record of staff asking the patient to sign a form indicating the patient understood that leaving was against medical advice.

A Froedtert nursing manager told inspectors that staff members don't have to try to get a signature, but the hospital's patient safety officer said that they do.

Despite flagging these issues, federal officials found the hospital to be in "substantial compliance" and eligible to continue receiving federal funding.

© Submitted by Andrea Ward Tashonna Ward

A spokesperson for Froedtert would not address specific issues but said in a statement that staff "work closely with internal quality resources and outside agencies to address any identified concerns." Froedtert officials have not submitted plans for correcting any issues to federal officials.

Ward’s death became a national news story as it raced across social media, sparking conversations about emergency care for black women, patients with heart problems and all patients facing long waits.

People across the country connected with posts Ward made on Facebook before her death as she grew angry about the wait time.

"She did everything she knew to do within her power," said Ward's cousin, Andrea Ward, who said the posts inspired the family to speak out. "That gave us our fight."

Ward got a ride from her sister to Froedtert on Jan. 2 and checked in at 4:58 p.m., according to her medical records. Staff checked her vital signs at 5:02 p.m. and determined her vital signs should be checked every two hours while she waited for further care.

Nurses didn’t check Ward’s vital signs until 7:29 p.m., 27 minutes beyond when she should have been checked, inspectors found. That’s around the time she left the hospital, according to the Milwaukee County Medical Examiner's Office, because she felt she was waiting too long to see a doctor.

When asked about the missed assessments, a manager told inspectors, “Yeah, they are late according to policy,” the report states.

ER patients face delays nationwide

Most of the delays found by inspectors at Froedtert are not surprising, said Amy Ho, an emergency medicine doctor in Texas who speaks nationally on health policy issues. Delays are a national problem, she said.

“We know this does happen with ER crowding,” Ho said. “It’s unsurprising to anyone who works in an ER that this might happen.”

Ho said crowding is caused in part by people relying on emergency rooms who might be better served by community clinics or specialists but don’t use those services because of insurance or other barriers.

Several studies show the root causes of ER overcrowding lie elsewhere in the hospital, such as inpatient staffing shortages, cumbersome admissions and discharge processes, inefficient lab testing and elective surgeries all being done in the early part of the week. Surgeons have resisted rescheduling elective surgeries, typically the most lucrative cases for hospitals.

The bottlenecks force patients to wait in the ER even after they have been admitted to the hospital. Called "boarding," the practice takes up valuable emergency room bed space and increases the wait time for patients.

“They (patients) often board for long times waiting for placements, especially when uninsured,” Ho said.

Another tactic to address overcrowding: Turning ambulances away and sending those patients to other hospitals. In 2014, Tiffany Tate was working at the Medical College of Wisconsin kitchen, about 350 yards from Froedtert's ER, when she suffered a stroke.

But Froedtert, the top hospital for stroke treatment in the region, was diverting patients at the time and Tate was taken to a less-qualified hospital. She later died.

A Milwaukee Journal Sentinel investigation into ambulance diversion found the little-known practice remains widely used by hospitals across the country, especially in urban areas, despite repeated studies that show it doesn't solve overcrowding, can put patients at risk and disproportionately harms the poor, sick and elderly.

Froedtert and other Milwaukee County hospitals agreed to stop turning away ambulances four years ago.

When the wait is too long

When ERs get overcrowded, patients may leave before getting vital care.

Ward expressed her frustrations on Facebook. At 7:35 p.m. that night, she wrote that she’d been told she might have to wait several hours to see a doctor.

“Idk what they can do about the emergency system at freodert (sic) but they damn sure need to do something,” she wrote. “I been here since 4:30 something for shortness of breath, and chest pains for them to just say it’s a two to SIX hour wait to see a dr.”

Froedtert publishes current wait times at froedtert.com/wait-times.

Past patients have spent an average of 4 hours, 44 minutes in Froedtert's emergency department before being admitted to the hospital, according to data from October 2017 to October 2018 compiled by ProPublica, though times vary widely based on the urgency of the condition and arrival time.

About 3% of patients in that period left Froedtert's emergency department without being seen, according to the data. Nationwide, it was about 2%.

When Ward left, there's no mention in her medical records of her signing a form indicating she was leaving "against medical advice" or any mention of staff encouraging her to stay.

After Ward left, Froedtert staff called her cellphone and her sister picked up, according to the medical examiner's report. By that point, Ward had collapsed and was already in an ambulance on her way back to Froedtert. She was pronounced dead soon after.

An attorney representing the family, Jeffrey Mitchell of the Cochran Firm, said his team is making a wrongful death claim. He said hospital officials were interested in mediation but that has not been scheduled. A spokesperson for Froedtert said he would not comment on legal matters.

Andrea Ward said the family has been contacted by countless others who said they've had similar problems getting help in ERs. She has educated herself and others about how to file complaints. She wants the momentum to lead to more than a financial settlement.

"It was not only Tashonna," Andrea said. "It is a broader pattern of what happens with our health care system.

"If there’s anything good that can come from this tragedy, perhaps it is that future deaths can be avoided."

Follow Rory Linnane on Twitter: @RoryLinnane.

This article originally appeared on Milwaukee Journal Sentinel: A 25-year-old teacher died after waiting hours at the ER. She's not the only one who saw delays.